Medicines,
Ethics and
Practice
Edition 43
July 2019M E P 2 0 1 9
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Details of the current national pharmacy board
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R OYA L P H A R M A C E U T I C A L S O C I E T Y
About
the Royal
Pharmaceutical
Society
C O P Y R I G H T © T H E R O YA L P H A R M A C E U T I C A L S O C I E T Y
2 0 1 9 . A L L R I G H T S R E S E R V E D . T H I S P U B L I C AT I O N M AY N O T
B E R E D I S T R I B U T E D O R R E P R O D U C E D I N W H O L E O R I N P A R T
W I T H O U T T H E P E R M I S S I O N O F T H E C O P Y R I G H T H O L D E R .
P U B L I C AT I O N M AY N O T B E R E D I S T R I B U T E D O R R E P R O D U C E D
I N W H O L E O R I N P A R T
We are the dedicated professional body for
pharmacists and pharmacy in England, Scotland
and Wales. We are the only body which represents
all sectors of pharmacy in Great Britain. We lead
and support the development of the pharmacy
profession including the advancement of science,
practice, education and knowledge in pharmacy.
We ensure the voice of the profession is heard
and actively promoted in the development and
delivery of healthcare policy and work to raise the
profile of the profession.
We put pharmacy at the forefront of healthcare
and are the world leader in the safe and
effective use of medicines. We are committed
to supporting and empowering our members
to make a real difference to improving health
outcomes for patients.M E P 2 0 1 9 1
Welcome to edition 43 of Medicines, Ethics
and Practice (MEP).
The MEP is a professional guide for pharmacists
and aspires to support pharmacists to practise
confidently and professionally; to use professional
judgement and to develop as a professional. It can
be used to support practice, learning and CPD.
Please note: the MEP will not always provide a
definitive solution to a problem however it can
be used to help you identify steps to resolve a
problem/issue in practice.
MEP evolves and develops with the support and
collaboration of members through the advice
and expertise of the MEP advisory group and
through feedback received from members
between editions.
The advisory group is composed of pharmacists
and aspiring pharmacists from different sectors,
different stages of practice and across Great
Britain who have volunteered their time to provide
advice to the RPS on the development of the MEP.
This edition of MEP has been edited by Rakhee Amin,
Senior Professional Standards Pharmacist.
We welcome volunteers from all sectors and stages
of practice willing to commit time to help us
develop MEP and also appreciate comments
and feedback; these can be sent to the RPS
Professional Support service on 0845 257 2570 or
0207 572 2737, or by email:
[email protected]
Copies of MEP are available for general
purchase at a cost of £55.00 and are available
from the Pharmaceutical Press website
at www.pharmpress.com or from Pharmaceutical
Press c/o Macmillan on tel: 01256 302 699.
Please note: Details of any corrections to the printed
and pdf of the MEP after publication can be found
on the RPS website www.rpharms.com.
Disclaimer
This publication is intended as a guide and may
not always include all information relating to its
subject matter. You should interpret all information
and advice in light of your own professional
knowledge and all relevant pharmacy and
healthcare literature and guidelines. Nothing in
this publication constitutes legal advice and
cannot be relied upon as such. Whilst care has
been taken to ensure the accuracy of content,
the Royal Pharmaceutical Society excludes to
the fullest extent permissible by law any liability
whether in contract, tort or otherwise arising
from your reliance on any information or advice.
Foreword2 M E P 2 0 1 9
C O N T E N T S
Contents
F O R E W O R D
1 C H A N G E S F O R T H I S E D I T I O N
2 C O R E C O N C E P T S A N D S K I L L S
2 . 1 PAT I E N T O R P E R S O N - C E N T R E D
H E A LT H C A R E
2 . 2 M E D I C I N E S O P T I M I S AT I O N
A N D P H A R M A C E U T I C A L C A R E
2 . 2 . 1 Medicines optimisation (England)
2 . 2 . 2 Pharmaceutical care (Scotland)
2 . 2 . 3 Pharmaceutical care and
prudent pharmacy (Wales)
2 . 2 . 4 Polypharmacy
2 . 3 P R O F E S S I O N A L I S M A N D
P R O F E S S I O N A L J U D G E M E N T
2 . 3 . 1 Professionalism
2 . 3 . 2 Professional judgement
2 . 3 . 3 Social media
2 . 3 . 4 Professional indemnity
2 . 4 P R O F E S S I O N A L E M P O W E R M E N T
2 . 5 C L I N I C A L C H E C K
2 . 5 . 1 Patient characteristics
2 . 5 . 2 Medication regimen factors
2 . 5 . 3 Administration and monitoring
2 . 5 . 4 Record keeping
2 . 6 T H E P H A R M A C I S T
C O N S U LTAT I O N I N P R A C T I C E
2 . 6 . 1 Medicines reconciliation
2 . 6 . 2 Helping patients to understand
their medicines
2 . 7 G E T T I N G T H E C U LT U R E R I G H T
2 . 7. 1 A just culture
2 . 8 P R O F E S S I O N A L D E V E L O P M E N T
2 . 8 . 1 Revalidation
2 . 8 . 2 RPS Faculty
2 . 8 . 3 RPS Foundation programme
2 . 8 . 4 Developing leadership
2 . 9 R E S E A R C H I N V O LV E M E N T
3 U N D E R P I N N I N G K N O W L E D G E
– L E G I S L AT I O N A N D
P R O F E S S I O N A L I S S U E S
3 . 1 C L A S S I F I C AT I O N O F
M E D I C I N E S
3 . 1 . 1 General Sale List (GSL) medicines
3 . 1 . 2 Pharmacy (P) medicines
3 . 1 . 3 Prescription-Only Medicines (POM)
3 . 2 P R O F E S S I O N A L A N D L E G A L
I S S U E S : P H A R M A C Y M E D I C I N E S
3 . 2 . 1 Pseudoephedrine and ephedrine
3 . 2 . 2 Oral emergency contraceptives
as pharmacy medicines
3 . 2 . 3 Paracetamol and aspirin
3 . 2 . 4 Codeine and dihydrocodeine
3 . 2 . 5 Reclassified medicines
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C L I C K O N
C O N T E N T H E A D E R S
T O N AV I G AT EM E P 2 0 1 9 3
3 . 3 P R O F E S S I O N A L A N D
L E G A L I S S U E S : P R E S C R I P T I O N
- O N LY M E D I C I N E S
3 . 3 . 1 General prescription requirements
3 . 3 . 2 Faxed prescriptions
3 . 3 . 3 Dental prescriptions
3 . 3 . 4 Forged prescriptions
3 . 3 . 5 Prescriptions from the EEA
or Switzerland
3 . 3 . 6 Military prescriptions
3 . 3 . 7 Labelling of dispensed
medicinal products
3 . 3 . 8 Administration
3 . 3 . 9 Patient specific directions and
administration, sale and supply
in hospitals and other settings
3 . 3 . 1 0 Exemptions: sale and supply
without a prescription
3 . 3 . 1 1 Dispensing self-prescribed
prescriptions and prescriptions
for close friends and family
3 . 3 . 1 2 Supplying oral retinoids
and pregnancy prevention
3 . 3 . 1 3 Dispensing valproate
for girls and women
3 . 3 . 1 4 Explaining biosimilar medicines
3 . 3 . 1 5 Summary of prescriber types
and prescribing restrictions
3 . 3 . 1 6 Checking registration of healthcare
professionals and additional
information on conditions of supply
3 . 3 . 1 7 Prescribing and dispensing
to the same person
3 . 3 . 1 8 Making things right when there's
been a dispensing error
3 . 4 W H O L E S A L E D E A L I N G
3 . 4 . 1 MHRA statement
3 . 4 . 2 Wholesale dealing of Controlled Drugs
3 . 4 . 3 Persons and organisations that can
receive medicines
3 . 4 . 4 Signed orders and record keeping
3 . 4 . 5 Supply and trade of medicines
3 . 4 . 6 Falsified Medicines Directive (FMD)
3 . 5 V E T E R I N A R Y M E D I C I N E S
3 . 5 . 1 Prescription requirements for POM-V,
POM-VPS and medicines supplied
under the veterinary cascade
3 . 5 . 2 The veterinary cascade
3 . 5 . 3 Labelling
3 . 5 . 4 Record keeping
3 . 5 . 5 Wholesale dealing
3 . 6 C O N T R O L L E D D R U G S
3 . 6 . 1 Background
3 . 6 . 2 Classification
3 . 6 . 3 Possession and supply
3 . 6 . 4 Administration
3 . 6 . 5 Import, export and travellers
3 . 6 . 6 Obtaining controlled drugs –
requisition requirements for
schedule 1, 2 and 3 controlled drugs
3 . 6 . 7 Prescription requirements for
schedule 2 and 3 controlled drugs
3 . 6 . 8 Collection of dispensed
controlled drugs
3 . 6 . 9 Safe custody
3 . 6 . 1 0 Destruction of controlled drugs
3 . 6 . 1 1 Record keeping and controlled
drugs registers
3 . 6 . 1 2 Practice issues: disposing
of spent methadone bottles
3 . 6 . 1 3 Practice issues:
needle exchange scheme
3 . 6 . 1 4 Extemporaneous methadone
3 . 6 . 1 5 Cannabis-based products
for medicinal use in humans
C O N T E N T S
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56
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1094 M E P 2 0 1 9
3 . 7 A D D I T I O N A L L E G A L A N D
P R O F E S S I O N A L I S S U E S
3 . 7 . 1 Expiry dates
3 . 7 . 2 Waste medicines
3 . 7 . 3 Requests for poisons and chemicals
3 . 7 . 4 Delivery and posting of medicines
to patients (including abroad)
3 . 7 . 5 Secure environments
3 . 7 . 6 Child-resistant packaging
3 . 7 . 7 Reporting adverse events
3 . 7 . 8 Emergency connection to
ex-directory telephone numbers
3 . 7 . 9 Homeopathic and herbal remedies
3 . 7 . 1 0 Charitable donation of medicines
3 . 7 . 1 1 Collection and purchase
of medicines by children
3 . 7 . 1 2 Protecting children and young people
3 . 7 . 1 3 Protecting vulnerable adults
3 . 7 . 1 4 Medical devices
3 . 7 . 1 5 Administration of adrenaline
in an emergency
3 . 7 . 1 6 Multi-compartment compliance aids
3 . 7 . 1 7 Drugs and driving
3 . 7 . 1 8 Retention of pharmacy records
3 . 7 . 1 9 New psychoactive substances
4 T H E R E S P O N S I B L E
P H A R M A C I S T
5 O T H E R R E S O U R C E S
P U B L I S H E D B Y T H E R O YA L
P H A R M A C E U T I C A L S O C I E T Y
6 P R O F E S S I O N A L S TA N D A R D S
7 R O YA L P H A R M A C E U T I C A L
S O C I E T Y C O D E O F C O N D U C T
8 W O R K I N G W I T H P A R T N E R S ,
A F F I L I AT E S A N D O T H E R
O R G A N I S AT I O N S
9 P H A R M A C I S T S U P P O R T
1 0 A P P E N D I C E S
A P P E N D I X 1
GPhC standards for pharmacy
professionals
A P P E N D I X 2
GPhC standards for registered
pharmacies
A P P E N D I X 3
GPhC in practice: guidance
on confidentiality
A P P E N D I X 4
GPhC in practice: guidance
on consent
A P P E N D I X 5
GPhC in practice: guidance
on raising concerns
A P P E N D I X 6
GPhC in practice: guidance on
maintaining clear sexual boundaries
A P P E N D I X 7
GPhC in practice: guidance on religion,
personal values and beliefs
A P P E N D I X 8
GPhC guidance on responding
to complaints and concerns
A P P E N D I X 9
GPhC guidance for registered
pharmacies preparing
unlicensed medicines
A P P E N D I X 1 0
GPhC guidance for registered
pharmacies providing pharmacy
services at a distance, including
on the internet
A P P E N D I X 1 1
GPhC guidance to ensure a safe
and effective pharmacy team
112
113
113
114
115
115
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116
116
117
118
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C O N T E N T SM E P 2 0 1 9 56 M E P 2 0 1 9
for this edition Changes 1
The following amendments
and additions have been
made for edition 43
N E W S E C T I O N S
2 . 2 . 4
P O LY P H A R M A C Y
2 . 3 . 4
P R O F E S S I O N A L I N D E M N I T Y
2 . 8 . 1
R E VA L I D AT I O N
3 . 3 . 1
G E N E R A L P R E S C R I P T I O N R E Q U I R E M E N T S
Falsified Medicines Directive (which came
into force on 9th February 2019)
3 . 3 . 1
G E N E R A L P R E S C R I P T I O N R E Q U I R E M E N T S
Prescriptions from the Crown Dependencies
(Jersey, Guernsey and Isle of Man)
3 . 6 . 1
C O N T R O L L E D D R U G S B A C K G R O U N D
Added a section on Gosport reportM E P 2 0 1 9 7
3 . 6 . 7
P R E S C R I P T I O N R E Q U I R E M E N T S F O R
S C H E D U L E 2 A N D 3 C O N T R O L L E D D R U G S
Added guidance on the rescheduling
of gabapentin and pregabalin
3 . 6 . 1 5
C A N N A B I S - B A S E D P R O D U C T S
F O R M E D I C I N A L U S E I N H U M A N S
A P P E N D I X 1 1
G P H C G U I D A N C E T O E N S U R E A S A F E
A N D E F F E C T I V E P H A R M A C Y T E A M
R E M O V E D S E C T I O N S
2 . 8 . 1 ( E D I T I O N 4 2 )
C O N T I N U I N G P R O F E S S I O N A L
D E V E L O P M E N T (C P D) R E P L A C E D W I T H
I N F O R M AT I O N O N R E VA L I D AT I O N
3 . 2 . 5 ( E D I T I O N 4 2 )
C O U G H A N D C O L D M E D I C I N E S
F O R C H I L D R E N
3 . 7. 3 ( E D I T I O N 4 2 )
C O S M E T I C C O N TA C T L E N S E S
( Z E R O P O W E R E D)
U P D AT E D S E C T I O N S
Updated references and further reading
signposting in all sections
2 . 2 . 2
P H A R M A C E U T I C A L C A R E , S C O T L A N D
At time of writing, the Chronic Medication
service had a name change to the Medicines
Care and Review Service
2 . 3 . 1
P R O F E S S I O N A L I S M
Added more examples of pharmacy
professionalism
2 . 3 . 3
S O C I A L M E D I A
Included reference to the use of Whatsapp
instead of bleeping colleagues
2 . 4
P R O F E S S I O N A L E M P O W E R M E N T
Moved section on Professional Empowerment
from 2.7 to 2.4 , to follow on from Professionalism
and Professional Judgement
2 . 9
R E S E A R C H I N V O LV E M E N T
Changes to examples of how the GPhC
standards apply to research
3 . 2 . 2
O R A L E M E R G E N C Y C O N T R A C E P T I V E S
A S P H A R M A C Y M E D I C I N E S
Included further guidance on religious and
moral beliefs impacting on the supply of EHC
3 . 2 . 3
PA R A C E TA M O L A N D A S P I R I N
Updates to Table 1 (OTC legal restrictions)
3 . 2 . 5
R E C L A S S I F I E D M E D I C I N E S
Updated further reading box to include signposting
to RPS guidance on the following:
• Anti-malarials as Pharmacy medicines
• Mometasone 0.05% nasal spray
• Oral lidocaine-containing products
for teething in children
3 . 3 . 1
G E N E R A L P R E S C R I P T I O N R E Q U I R E M E N T S
Added signposting to information on EPS and CDs
in the ‘Electronic Prescriptions’ box in this section
3 . 3 . 1
G E N E R A L P R E S C R I P T I O N R E Q U I R E M E N T S
Repeatable prescriptions: added reference
to use in hospitals and homecare settings,
and updated guidance on prisons
3 . 3 . 6
M I L I TA R Y P R E S C R I P T I O N S
Updated in line with current practice
3 . 3 . 8
A D M I N I S T R AT I O N
Updated to current guidance as published
in RPS Professional guidance on the administration
of medicines in healthcare settings 2019 and
RPS Professional guidance on the safe and secure
handling of medicines 2018 www.rpharms.com
3 . 3 . 1 2
S U P P LY I N G I S O T R E T I N O I N A N D
P R E G N A N C Y P R E V E N T I O N
Updated this section to include information
on all oral retinoids. Title changed to ‘SUPPLYING
ORAL RETINOIDS AND PREGNANCY PREVENTION’
C H A N G E S F O R T H I S E D I T I O N8 M E P 2 0 1 9
3 . 3 . 1 5
S U M M A R Y O F P R E S C R I B E R T Y P E S
A N D P R E S C R I B I N G R E S T R I C T I O N S
Updated table 4: Different types of prescriber
and restrictions on what can be prescribed –
to include information on the following prescribers:
• Physiotherapist and Podiatrist independent
prescriber – added signposting to Health
and Care Professionals Council (HCPC) and
NHS England have issued a joint statement
(www.hcpc-uk.org/registrants/updates/2019/
reclassification-of-gabapentin-and-pregabalin)
on the reclassification of gabapentin and
pregabalin giving details of which prescribers
can issue prescriptions for CDs
• Paramedic independent prescriber
3 . 3 . 1 6
C H E C K I N G R E G I S T R AT I O N O F
H E A LT H C A R E P R O F E S S I O N A L S A N D
A D D I T I O N A L I N F O R M AT I O N O N
C O N D I T I O N S O F S U P P LY
Updated table 5 to include information on
advanced paramedics prescribing medicines
3 . 4
W H O L E S A L E D E A L I N G
Added section 3.4.6 on Falsified
Medicines Directive (FMD)
3 . 6 . 2
C O N T R O L L E D D R U G S C L A S S I F I C AT I O N
Added reference to new the section on cannabis
based products for medicinal use in humans
(3.6.15) and the rescheduling of gabapentin
and pregabalin to Schedule 3 CD
3 . 6 . 7
P R E S C R I P T I O N R E Q U I R E M E N T S F O R
S C H E D U L E 2 A N D 3 C O N T R O L L E D D R U G S
• Replaced Formulation with Form in line with the
Misuse of Drugs Regulations 2001
• Updated guidance on the Total Quantity to provide
clarification on expressing it as the total number
of dosage units or the total quantity of the drug.
Included reference to Home Office advice on
expressing the quantity of different strength tablets
of the same CD on the prescription
• Added signposting information on CD
electronic prescriptions
• Added further guidance on the using the approved
Home Office wording for instalment prescribing
of CDs during periods when pharmacy is closed
• Updated printing errors in table 13 CONTROLLED
DRUGS PRIVATE PRESCRIPTION FORMS on the type
of form used in England and Wales
3 . 7. 8
E M E R G E N C Y C O N N E C T I O N T O
E X - D I R E C T O R Y T E L E P H O N E N U M B E R S
Updated in line with advice from BT
3 . 7. 1 1
C O L L E C T I O N A N D P U R C H A S E
O F M E D I C I N E S B Y C H I L D R E N
Updated to consider additional factors
on whether supply of dispensed medicines
is appropriate or not
3 . 7. 1 7
D R U G S A N D D R I V I N G
Included signposting to information on new
safety laws being introduced in Scotland during
October 2019
3 . 7. 2 0
N E W P S Y C H O A C T I V E S U B S TA N C E S
Removed detailed information on what NPS
are – signposted to the RPS website for information
in the quick reference guide and factsheet
6
P R O F E S S I O N A L S TA N D A R D S
Added to the list – professional standards
and framework currently under development
7
R P S C O D E O F C O D U C T
Updated RPS Code of Conduct reproduced
G P H C A P P E N D I C E S
Updated in line with any changes GPhC has made
to the contents of their standards and guidance
and included the following changes:
• Title change of Appendix 7 ‘GPhC guidance on
the provision of pharmacy services affected by
religious and moral beliefs’ to ‘GPhC in practice:
Guidance on religion, personal values and beliefs’
• Significant changes to Appendix 10 ‘GPhC guidance
for registered pharmacies providing pharmacy
services at a distance, including on the internet’
as revised by GPhC in April 2019
C H A N G E S F O R T H I S E D I T I O NM E P 2 0 1 9 92.1
Patient or personcentred healthcare
2.2
Medicines optimisation
and pharmaceutical care
2.3
Professionalism and
professional judgement
2.4
Professional empowerment
2.5
Clinical check
2.6
The pharmacist
consultation in practice
2.7
Getting the
culture right
2.8
Professional
development
2.9
Research
involvement
Core concepts and skills 2C O R E C O N C E P T S A N D S K I L L S
M E P 2 0 1 9 1 1
This section on core concepts will equip you
with knowledge and skills to help you practise
confidently and professionally as a pharmacist.
2.1
Patient or personcentred healthcare
The concept of patient or person-centred
healthcare is important to all health and social
care professionals, and is integrated into
healthcare policy throughout Great Britain.
Common themes are:
• Treating patients as people and as equal
partners in decisions about their care
• Putting people at the centre of all decisions
• Respect for patient preferences
• Compassion, dignity and empathy
• Support for self-care, enablement, autonomy
and independence
• Patient choice, control and influence
• Good communication.
Examples of person-centred healthcare
in practice include:
• People being called by the name they prefer
rather than by the name on official documentation
(e.g. prefer being called Mike instead of Michael)
• Being asked to do something and not being told
• Being able to make informed choices
• Being able to speak openly about their experiences
of taking or not taking medicines (including any
complaints or concerns they have with their
medicines/services received). Their views about
what medicines mean to them, and how medicines
impact on their daily life (e.g. when to wake up,
when to sleep)
• Involving people in decisions about their
medicines and self care (including listening to
patients (or relatives) when they raise concerns
about their medicines/treatment)
• Identify problematic polypharmacy and having
a shared decision making process on managing this
• Explain your role(s) clearly and explicitly
to patients
F U R T H E R R E A D I N G
Royal Pharmaceutical Society
Your care, your medicines. Pharmacy
at the heart of patient-centred care.
www.rpharms.com
Health Foundation
Person-centred care made simple. What everyone
should know about person-centred care.
www.health.org.uk
National Voices
Person-centred care in 2017 – Evidence from
service users.
www.nationalvoices.org.uk/publications/
our-publications/person-centred-care-2017
NHS England
Developing patient-centred care.
www.england.nhs.uk/integrated-care-pioneers/
resources/patient-care
NHS Scotland Quality Improvement Hub
Person-centred care.
www.qihub.scot.nhs.uk/default.aspx
Public Health Wales
1000 Lives Improvement.
www.1000livesplus.wales.nhs.uk
2.2
Medicines
optimisation and
pharmaceutical
care
2 . 2 . 1 M E D I C I N E S O P T I M I S AT I O N
(E N G L A N D)
2 . 2 . 2 P H A R M A C E U T I C A L C A R E
(S C O T L A N D)
2 . 2 . 3 P H A R M A C E U T I C A L C A R E A N D
P R U D E N T P H A R M A C Y (WA L E S)
2 . 2 . 4 P O LY P H A R M A C YC O R E C O N C E P T S A N D S K I L L S
1 2 M E P 2 0 1 9
The contact you have with people receiving
healthcare allows the profession to champion
a person-centred approach. This enables better
outcomes through medicines optimisation
(England), pharmaceutical care (Scotland)
and pharmaceutical care and prudent
pharmacy (Wales).
2 . 2 . 1
M E D I C I N E S O P T I M I S AT I O N
E N G L A N D
• Medicines optimisation is about ensuring that
patients get the best possible outcomes from
their medicines. The first step is to ensure that the
right patients get the right choice of medicine,
at the right time. But the focus needs to be on
the individual patient, their beliefs and their
experiences. The goal is to help patients to:
• improve their outcomes
• take their medicines correctly
• improve adherence
• avoid taking unnecessary medicines
• reduce wastage of medicines
• improve medicines and patient safety.
Ultimately, medicines optimisation can help
encourage patients to take ownership of
their treatment.
It is a patient-focused approach to getting the best
from investment in and use of medicines. It requires
a holistic approach, an enhanced level of patientcentred professionalism, and partnership between
clinical professionals and a patient.
E L E M E N T S O F M E D I C I N E S
O P T I M I S AT I O N
To empower patients and the public to make
the most of medicines healthcare professionals
need to understand the concept of medicines
optimisation. Diagram 1 outlines the seven elements
of medicines optimisation which comprise
of the four principles as well as measurement
and monitoring, improved patient outcomes,
and ensuring a patient-centred approach.
These describe medicines optimisation in practice
and the outcomes it is intended to impact.
D I A G R A M 1 :
S U M M A R Y O F T H E F O U R P R I N C I P L E S
O F M E D I C I N E O P T I M I S AT I O N
P R I N C I P L E 1 :
A I M T O U N D E R S TA N D
T H E P AT I E N T ’ S E X P E R I E N C E
To ensure the best possible outcomes from
medicines, there is an ongoing, open dialogue
with the patient and/or their carer about the
patient’s choice and experience of using medicines
to manage their condition; recognising that the
patient’s experience may change over time even
if the medicines do not.
P R I N C I P L E 2 :
E V I D E N C E - B A S E D C H O I C E
O F M E D I C I N E S
Ensure that the most appropriate choice
of clinically and cost-effective medicines (informed
by the best available evidence base) are made
which can best meet the needs of the patient.
P R I N C I P L E 3 :
E N S U R E M E D I C I N E S U S E
I S A S S A F E A S P O S S I B L E
The safe use of medicines is the responsibility
of all professionals, healthcare organisations and
patients, and should be discussed with patients
and/or their carers. Safety covers all aspects
of medicines usage, including unwanted effects,
interactions, safe processes and systems, and
effective communication between professionals.
PAT I E N T -
C E N T R E D
A P P R O A C H
I M P R O V E D P
AT I E N T O U T
C O M E S
A L I G N E D M E A
S U R E M E N T & M O
N I T O R I N G O F M
E D I C I N E S O P T
I M I S A T I O N
Aim to und
erstand th
e
patient
’s ex
perienc
e
1
Evidence
-based ch
oice
of medi
cines
2
-ation part o
f rout
ine pract
ice
M 4
ake med
icine opt
imisis as sa
fe as poss
ible
E 3
nsure med
icines useC O R E C O N C E P T S A N D S K I L L S
M E P 2 0 1 9 1 3
P R I N C I P L E 4 :
M A K E M E D I C I N E S O P T I M I S AT I O N
P A R T O F R O U T I N E P R A C T I C E
Health professionals routinely discuss with each
other and with patients and/or their carers how
to get the best outcomes from medicines
throughout the patient’s care.
Further detail on medicines optimisation and
the above principles is available on the RPS website
in guidance titled Helping patients make the
most of their medicines: Good practice guidance
for healthcare professionals in England
www.rpharms.com
F U R T H E R R E A D I N G
Royal Pharmaceutical Society
Medicines optimisation hub.
www.rpharms.com
National Institute for Health and Care Excellence
Medicines optimisation: the safe and effective
use of medicines to enable the best possible
outcomes. NICE guideline. 2015.
www.nice.org.uk
NHS England
Medicines optimisation hub.
www.england.nhs.uk
2 . 2 . 2
P H A R M A C E U T I C A L C A R E
S C O T L A N D
Pharmaceutical care evolved from clinical
pharmacy practice in the hospital setting and was
defined in 1990 as: ‘the responsible provision of
drug therapy for the purpose of achieving definite
outcomes that improve the patient’s quality of life.’
Pharmaceutical care is a person-centred
philosophy and practice that aims to optimise
the benefits of drug therapy and minimise the
risk of drug therapy to patients by providing
the framework for pharmacists to apply their
knowledge and skills. The pharmacist will
assess the pharmaceutical needs of patients
and take responsibility for meeting those needs
in collaboration with other health and social
care professionals.
Key components are:
• The patient assessment to identify unmet
pharmaceutical care needs and issues
• The development of a pharmaceutical care plan
to document the needs identified
• To agree patient outcomes, the actions required
or taken and the follow-up required.
In Scotland pharmaceutical care has become the
cornerstone of national policy and practice in all
settings. Pharmaceutical care is embedded within
undergraduate and postgraduate education, the
community pharmacy contractual framework and
clinical pharmacy services within hospital and
primary care, including pharmacist prescribing.
In practice, the assessment will identify
any pharmaceutical care issues with
concordance and sets out to establish within
the available information:
• If the drug therapy and dose is appropriate for
the condition in this patient
• If any additional therapy (drug and
non-pharmacological) is required
• If the drug therapy and dose is safe
• If the person is suffering from any avoidable
side effects
• If the drug therapy, dose and non-pharmacological
therapy are effective and achieving a defined
desired outcome.
It is a holistic philosophy and practice that will
also identify and address the following needs:
• Public health, educational, medicines
management,non-pharmacological
management and changes in clinical need.
Achieving excellence in pharmaceutical care:
a strategy for Scotland (published in Aug 2017)
aims to transform the role of pharmacy across all
areas of pharmacy practice, increase capacity,
and offer the best person-centred care. The vision
is for pharmacy as an integral and enhanced part
of a modern NHS in Scotland. See full document
for further details www.gov.scot/publications/
achieving-excellence-pharmaceutical-carestrategy-scotlandC O R E C O N C E P T S A N D S K I L L S
14 M E P 2 0 1 9
F U R T H E R R E A D I N G
Clinical Resource and Audit Group National
Health Service in Scotland
Clinical Pharmacy in the Hospital Pharmaceutical
Service: a Framework for Practice. 1996.
Clinical Resource and Audit Group.
Scottish Office.
Clinical Pharmacy Practice in Primary Care;
a framework for the provision of community-based
NHS pharmaceutical services. 1999.
Hepler CD, Strand LM
Opportunities and responsibilities
in pharmaceutical care.
American Journal of Hospital Pharmacy.
March 1990, Volume 47, p533-543.
www.ncbi.nlm.nih.gov/pubmed/2316538
NHS Scotland Community Pharmacy
Medicines Care and Review Service
(At the time of writing the MEP, the Chronic
Medication Services is changing its name
to the Medicines Care and Review Service).
www.communitypharmacy.scot.nhs.uk
Scottish Government
Achieving excellence in pharmaceutical care:
a strategy for Scotland, Aug 2017.
www.gov.scot
2 . 2 . 3
P H A R M A C E U T I C A L C A R E
A N D P R U D E N T P H A R M A C Y
WA L E S
Your Care, Your Medicines: Pharmacy at
the heart of patient centred care presents
a vision for pharmacy in Wales.
It is the result of work led by the Welsh
Pharmaceutical Committee, the committee
responsible for advising the Welsh Government
on pharmacy issues. It has been supported
by the RPS with contributions from leaders
from all sectors of the profession. It is an ambition
that takes into account the current policy drivers
for healthcare in Wales that will contribute to:
• The delivery of prudent healthcare
• A change in culture to encourage greater
co-production with patients and collaborative
working between health professionals
• A rebalancing of services between health care
sectors to deliver an increased primary carebased focus
• Creating seamless patient care and closing
the gaps between services
• Empowering people to take greater responsibility
for their own health and wellbeing.
The model of pharmacy engagement presented
in Your Care, Your Medicines (Diagram 2)
demonstrates patient interactions with the
pharmacy team at various points of their
healthcare journey.
The ambition is for patients in Wales to be put
at the centre of their care, to benefit from the full
integration of the pharmacy team into the NHS and
to ensure every intervention involving medicines is
supported, communicated and coordinated across
the health and social care system.
The key ambitions in the document are:
A M B I T I O N 1
Patients will routinely access health promotion
advice and self-care support from the pharmacy
team. This will include healthy lifestyle information,
medicines advice and opportunistic interventions
at the point of medicines supply.
Advances in technology will be exploited to
maximise benefits for patients in accessing
pharmacy support.
A M B I T I O N 2
The people of Wales will benefit from early
detection and treatment of health conditions
when engaging with the pharmacy team.
Patients will expect the symptoms of minor ailments
and non-life threatening emergencies to be treated
by the pharmacy team and to be referred to other
health services when symptoms require further
and more specialised investigation and treatment.
A M B I T I O N 3
Patients with chronic conditions will have regular
reviews with a pharmacist who will provide
medication advice and coaching in a setting that
is most suitable for the patient. A pharmaceutical
care plan will be initiated, discussed and jointly
managed between the patient and the pharmacist
and made available to other health professionals
involved in the patient’s care.C O R E C O N C E P T S A N D S K I L L S
M E P 2 0 1 9 1 5
A M B I T I O N 4
When patients require planned hospital care
or any intensive health care they will feel
confident that a holistic approach is taken
to the management of their conditions and that
all decisions on medication changes will be led
by expert advice from the pharmacy team.
A M B I T I O N 5
Patients with supported living needs, whether living
independently in their own homes or in a care home
setting, must benefit from access to the pharmacy
team to help manage their medicines effectively
and to maintain their health and wellbeing.
A M B I T I O N 6
Patients with palliative care and end of life care
needs will be treated with dignity and respect and
empowered to shape their clinical pathway with
support from the pharmacy team.
F U R T H E R R E A D I N G
Royal Pharmaceutical Society
Your care, your medicines:
Pharmacy at the heart of patient-centred care
www.rpharms.com
Further information on the prudent agenda
can be found at www.prudenthealthcare.org.uk
2 . 2 . 4
P O LY P H A R M A C Y
The RPS has published guidance on
polypharmacy for pharmacists and all
healthcare organisations involved with
medicines. It provides a summary of the scale
and complexity of the issue of polypharmacy.
It outlines how healthcare professionals,
patients and carers can find solutions when
polypharmacy causes problems for patients
and points to useful resources that can help.
It recommends that all healthcare organisations
have systems in place to ensure people taking
multiple medicines (especially those taking
10 or more) can be identified and highlighted
as requiring a comprehensive medication
review with a pharmacist.
The benefits of such reviews include:
• A reduction in problematic polypharmacy
• Improved health
• Patients more likely to take their medicines
• Fewer wasted medicines
The guidance titled ‘Polypharmacy: Getting our
medicines right’ can be viewed on the RPS website
at www.rpharms.com
PA L L IATIVE CAR E & E
N D OF LI FE
R ES I D ENTIAL CARE & H
OME SU PPORT
I N T E N S I V E I N T E
R V E N T I ON & M
AN AG EM E N T
M E D I C I N E S M
A N AG EM E N T F
O R C H RO N I C C
O N D I T I O N S
P R E - S CR E E
N I N G & U N
S C H E D U L E
D CA R E
S U P P O R
T FO R C
O M M O N A
I L M E N T
S
SUPP
ORT F
OR HE
ALTH & W
EL LBEI
NG
D I A G R A M 2 : M O D E L O F
P H A R M A C Y E N G A G E M E N TC O R E C O N C E P T S A N D S K I L L S
1 6 M E P 2 0 1 9
2.3
Professionalism
and professional
judgement
2 . 3 . 1 P R O F E S S I O N A L I S M
2 . 3 . 2 P R O F E S S I O N A L J U D G E M E N T
2 . 3 . 3 S O C I A L M E D I A
2 . 3 . 4 P R O F E S S I O N A L I N D E M N I T Y
Pharmacy is a profession and pharmacists are
professionals who exercise professionalism and
professional judgement on a day-to-day basis.
The concepts of a ‘profession’, a ‘professional’
and ‘professionalism’ are not rigidly defined.
However, these are concepts that are important
for any pharmacist, including those who work
in non-patient facing roles.
A profession can be described as:
• An occupation that is recognised by the public
as a profession
• An occupation for which there is a recognised
representative professional body
• An occupation that benefits from professional
standards and codes of conduct
• An occupation that is regulated to ensure the
maintenance of standards and codes of conduct
A professional can be described as:
• A member of a profession
• A member of a professional body
• An individual who:
• Behaves and acts professionally
• Exercises professionalism
and professional judgement
• Has professional values,
attitudes and behaviours
2 . 3 . 1
P R O F E S S I O N A L I S M
Pharmacy professionalism can be defined as
a set of values, behaviours and relationships that
underpin the trust the public has in pharmacists.
Examples of these are:
• Altruism
• Appropriate accountability
• Compassion
• Duty
• Excellence and continuous improvement
• Honour and integrity
• Professional judgement
• Respect for other patients, colleagues and other
healthcare professionals (including listening
to and acting on feedback when needed)
• Working in partnership with patients, doctors
and the wider healthcare team in the patient’s/
public’s best interest
• Work within competence
• Ensure patient is placed at the centre
of all decision making
• Being honest about scope of practice
• Knowing when to seek support
Many of these values, attitudes and behaviours
are also reflected in the mandatory GPhC Standards
for pharmacy professionals (see Appendix 1)
Pharmacists who are working in industry should
also adhere to the Association of the British
Pharmaceutical Industry (ABPI) Code of Practice
for the Pharmaceutical Industry (www.abpi.org.uk)
D E C L A R I N G C O N F L I C T S
O F I N T E R E S T
It is important to declare conflicts of interest
appropriately whether they are actual or potential.
An actual conflict of interest is when one or more
interests materially conflict.
A potential conflict of interest is where there
is a possibility of a conflict between one or more
interests in the future.C O R E C O N C E P T S A N D S K I L L S
M E P 2 0 1 9 1 7
Some examples of conflicts of interest include:
• Having another job or receiving consultancy fees
(i.e. having an outside employment) which impacts
upon another role
• Receiving or being offered gifts from patients
or suppliers to the NHS or your employer
• Receiving or being offered hospitality such
as travel, accommodation, meals or refreshments
e.g. in relation to attending a meeting, conference
or training event
• Receiving or being offered sponsorship for events,
research grants or posts
• Owning shares in a company whose value could
be influenced by your role
• Having an indirect interest or non-financial interest
e.g. If a spouse, close relative, business partner or
close friend has an interest
• Receiving any other payments or ‘transfers of value’.
Declarations will most commonly be made to:
• Your employer through a line manager, governance
or conflict lead
• Someone commissioning your services
• A chairperson at the meetings which you attend
A declaration of an interest does not necessarily
prevent an individual from carrying out a role, but it
ensures that there can be no perception that they
are seeking to influence decisions improperly.
2 . 3 . 2
P R O F E S S I O N A L J U D G E M E N T
Professional judgement can be described as the
use of accumulated knowledge and experience,
as well as critical reasoning, to make an informed
professional decision – often to help solve a
problem presented by, or in relation to, a patient;
or policies and procedures affecting patients.
It takes into account the law, ethical considerations,
relevant standards and all other relevant factors
related to the surrounding circumstances.
Furthermore, it will resonate with the core values,
attitudes and behavioural indicators
of professionalism.
H O W D O I E X E R C I S E
P R O F E S S I O N A L J U D G E M E N T ?
Many pharmacists exercise their professional
judgement instinctively but it may be helpful
to break the process down into smaller steps:
D I A G R A M 3 :
E X E R C I S I N G P R O F E S S I O N A L J U D G E M E N T
1
Identify the ethical dilemma or professional issue
you are faced with, e.g. deciding whether to supply
a medicine or not.
2
Gather all the relevant information and research
the problem – i.e. obtain the following:
• Facts
• Knowledge
• Laws
• Standards
• Good practice guidance
• Advice from support services, head office, line
managers or colleagues.
3
Identify all the possible options.
4
Weigh up all the benefits and risks, advantages
and disadvantages of each of the possible options
you have identified.
1 . I D E N T I F Y T H E E T H I C A L D I L E M N A
O R P R O F E S S I O N A L I S S U E
2 . G AT H E R R E L E VA N T I N F O R M AT I O N
3 . I D E N T I F Y T H E P O S S I B L E O P T I O N S
4 . W E I G H U P T H E B E N E F I T S A N D
R I S K S O F E A C H O P T I O N
5 . C H O O S E A N O P T I O N
6 . R E C O R DC O R E C O N C E P T S A N D S K I L L S
1 8 M E P 2 0 1 9
5
Choose an option. It is important you can justify
the decision you have made because often when
faced with an ethical dilemma or professional
issue pharmacists are weighing up conflicting
obligations which could be genuine patient
interest, legal obligations, professional standards,
public interest, contractual Terms of Service and
company policies.
6
It is important to make a record of the decisionmaking process and your reasons leading to
a particular course of action where appropriate.
This may be a record in the patient’s medication
record (PMR), medical record, the back of the
prescription register or an intervention record
book. This is important as evidence of the thought
processes leading to a decision.
It is entirely possible for two different pharmacists,
faced with the same facts and circumstances,
to choose two different courses of action. This is
the nature of a finely balanced ethical dilemma.
Both options could be justifiable and legitimate
choices for a significant proportion of pharmacists
if faced with the same dilemma.
It is important to point out that professional
judgement is not a blanket defence or a blanket
reason to take the most convenient choice.
It must be exercised properly, logically and for
valid reasons. If there are mechanisms to achieve
the required goal it would be risky to choose an
illegal alternative. For example, lending medication
would be very difficult to justify if an emergency
supply could have been used.
The process of making a professional judgement
is underpinned by knowledge. The following
chapters of the MEP provide information on the
core knowledge required by pharmacists in their
day-to-day practice.
F U R T H E R R E A D I N G
Royal Pharmaceutical Society
Joint statement on conflicts of interest.
www.rpharms.com
Association of the British Pharmaceutical Industry
Disclosure of payments to individual healthcare
professionals. 2015.
www.abpi.org.uk
Elvey R, Lewis P, et al
Patient-centred professionalism among
newly registered pharmacists. 2011.
www.pharmacyresearchuk.org select the
‘Our research’ and ‘Download a report’ tabs.
General Pharmaceutical Council
Demonstrating professionalism online. 2016.
www.pharmacyregulation.org
General Pharmaceutical Council
Joint statement on professional duty of candour.
www.pharmacyregulation.org
NHS England
Managing conflicts of interest in the NHS.
www.england.nhs.uk/ourwork/coi
Schafheutle E, Hassell K, et al
Professionalism in pharmacy education. 2010.
www.pharmacyresearchuk.org select the
‘Our research’ and ‘Download a report’ tabs.
Wingfield J, Pitchford K, editors
Dale and Appelbe’s Pharmacy and Medicines Law.
11th edition. 2017. London; Pharmaceutical Press.
www.pharmpress.com
2 . 3 . 3
S O C I A L M E D I A
Pharmacists and aspiring pharmacists who use
social media and social networking* should do
so responsibly and with the same high standards
which they would apply in real world interactions.
It is important to maintain proper professional
boundaries in relationships and interactions
with patients and at all times to respect the
confidentiality of others, including patients
and colleagues.
Be aware of the potential audience of your online
activity, that this may be publicly accessible,
circulated and shared beyond your control.
This activity could impact upon your professional
image and the reputation of the profession as
a whole.
Organisations may use social media, such as
Whatsapp, to communicate with healthcare
professionals in other departments (i.e between
wards), instead of bleeping them. It is important
pharmacists understand and follow their company
or NHS Trust policies on this practice.C O R E C O N C E P T S A N D S K I L L S
M E P 2 0 1 9 1 9
*Social media includes blogging, web forums
including professional web forums, Twitter,
Facebook, online, Whatsapp messaging and
virtual networks (this list is not exhaustive).
F U R T H E R R E A D I N G
Royal Pharmaceutical Society
Social media guidance – toolkit.
www.rpharms.com
British Medical Association
Social Media Use: Practical and ethical
guidance for doctors and medical students.
www.bma.org.uk
General Pharmaceutical Council
Demonstrating professionalism online. 2016.
www.pharmacyregulation.org
General Pharmaceutical Council
Guidance for registered pharmacies providing
pharmacy services at a distance, including
on the internet. 2015.
www.pharmacyregulation.org
(see MEP Appendix 10)
General Pharmaceutical Council
Guidance on patient confidentiality. 2018.
www.pharmacyregulation.org (see MEP Appendix 3)
Health and Care Professionals Council
Guidance on the use of social media.
www.hcpc-uk.org
NHS Digital
Social media security: user guide.
www.digital.nhs.uk
NHS Education for Scotland
Core clinical assessment skills courses
(two-day training course).
www.nes.scot.nhs.uk
Royal College of General Practitioners
Social Media Highway Code.
www.rcgp.org.uk
2 . 3 . 4
P R O F E S S I O N A L I N D E M N I T Y
It is a requirement if you are registered with
the GPhC that you have professional indemnity
insurance in place before you start working
in your role.
The GPhC has advised "that the professional
indemnity arrangement you have in place
provides appropriate cover. This means that
the cover needs to be appropriate to the nature
and extent of the risks involved in your practice."
Further information and useful FAQs can be viewed
on the GPhC website at www.pharmacyregulation.
org/professional-indemnity-requirements.
Please contact the RPS Professional Support
team if you wanted to discuss further.
2.4
Professional
empowerment
Professional empowerment is about enabling
professionalism.
At an individual level for pharmacists and future
pharmacists, it is about the development
of knowledge; development of skills, experience
and confidence; and the cultivation of professional
values and behaviours which collectively imbue
the pharmacist with authority, empowering and
enabling professionalism.
At a wider level it is about creating an
environment around an individual which enables
all of the above.
Professional training starts at university and is
enhanced with pre-registration training by learning,
pre-registration tutors and training programmes.
In professional practice it is self-cultivated through
continuing professional development (CPD),
continuing education, and supported by the RPS
through our Foundation and Faculty professional
development programmes.
The GPhC standards for registered pharmacies
require that staff are empowered and competent
to safeguard the health, safety and wellbeing
of patients and the public (see Appendix 2 for
further information).
The RPS contributes to creating empowerment
through guidance, standards, news and alerts;
through webinars and our mentoring programme;
through our Leadership Development Framework;
through influencing policy and embedding and
nurturing the right culture (see section 2.7).C O R E C O N C E P T S A N D S K I L L S
20 M E P 2 0 1 9
In 2011 we published Reducing workplace pressure
through professional empowerment a resource
which discusses various ways to reduce workplace
pressure, including:
• Mechanisms for raising concerns
• Promoting management skills
• Ensuring pharmacists take breaks
• Professionalism and commercial pressures
• Job satisfaction
Employers play a key role by providing structured
training resources and events; conferences;
opportunity and time for CPD; support from the
superintendent or office of the superintendent;
company alerts and updates; developing and
implementing the right organisation culture which
enables professional empowerment.
Other pharmacy organisations, stakeholders
and training providers are also integral to enabling
professionalism through training, and enabling the
right environment for professionalism to flourish,
including through getting the culture right.
F U R T H E R R E A D I N G
Royal Pharmaceutical Society
Leadership development framework
and accompanying handbook.
www.rpharms.com
Royal Pharmaceutical Society
Reducing workplace pressure through
professional empowerment. 2011.
www.rpharms.com
Royal Pharmaceutical Society
Working as a locum in community
pharmacy – quick reference guide.
www.rpharms.com
General Pharmaceutical Council
Guidance to support the standards
for registered pharmacies.
www.pharmacyregulation.org
2.5
Clinical check
2 . 5 . 1 PAT I E N T C H A R A C T E R I S T I C S
2 . 5 . 2 M E D I C AT I O N R E G I M E N FA C T O R S
2 . 5 . 3 A D M I N I S T R AT I O N A N D
M O N I T O R I N G
2 . 5 . 4 R E C O R D K E E P I N G
One of the key skills of a pharmacist is to
perform a clinical assessment or clinical check
for medicines to be supplied or administered.
Clinical checks involve identifying potential
pharmacotherapeutic problems by collating
and evaluating all relevant information, including
patient characteristics, disease states, medication
regimen and, where possible, laboratory results.
Importantly, it is not a mere dose and interaction
check, or a simple tick box exercise but rather
a complex activity which often requires interaction
with patients and healthcare professionals.
A clinical check is underpinned by knowledge
of human pathophysiology as well as medicines
(pharmacokinetics, pharmacology, pharmaceutics,
pharmacognosy) coupled with clinical experience
and the rational application of professional
judgement. It is a key part of clinical pharmacy
contributing to patient safety and public health.
By using a structured, logical approach to
a clinical check, you can balance the risks and
benefits of a prescribed medicine regimen and,
in doing so, improve the medicine’s safety
and effectiveness.
O B TA I N I N G I N F O R M AT I O N
The sources for obtaining information, and the
level of detail available, will vary depending
on the pharmacy setting. It may not always be
practicable to obtain all the information needed
and sometimes, decisions will need to be made
on limited information. You should consider the
level of risk when deciding if further information
is required from one or more additional sources.
M E P 2 0 1 9C O R E C O N C E P T S A N D S K I L L S
M E P 2 0 1 9 2 1
In primary care, you may be able to obtain
information from:
• The prescription
• The patient, patient’s representative or carer
• The patient’s GP or other healthcare
professionals involved in the patient’s care
• The patient’s medication record
• Other patient medical records where available
(e.g. in Scotland – access to the Emergency
Care Summary; access to the Summary Care
Record where available; in a prison – access
to medical records).
In secondary care, additional sources of
information available would include other
healthcare professionals involved in the patient’s
care (e.g. dieticians, microbiologists and
physiotherapists), medical and nursing care notes,
additional ward charts and laboratory results.
The areas that you need to consider when
undertaking a clinical check include:
• Patient characteristics
• Medication regimen
• How treatment will be administered and monitored
2 . 5 . 1
PAT I E N T C H A R A C T E R I S T I C S
Factors relating to patient characteristics that
should be considered during a clinical check include:
P AT I E N T T Y P E
Establish whether the patient falls into a group
where treatment is contraindicated or cautioned.
Specific groups of patients to be aware of include:
• Children
• Women who are pregnant or breastfeeding
• The elderly
• Certain ethnic groups – a patient’s ethnic origin
can affect the choice of medicine or dose
(e.g. the initial and maximum dose of rosuvastatin
is lower for patients of Asian origin)
• For some medicines, the gender of the patient
should be considered. For example, finasteride
is contraindicated for women
C O - M O R B I D I T I E S
Patient co-morbidities, such as renal or hepatic
impairment or heart failure, can exclude the
use of a particular treatment or necessitate
dose adjustments.
P AT I E N T I N T O L E R A N C E S
A N D P R E F E R E N C E S
Other patient factors that can affect the choice
of treatment include known medication adverse
events (e.g. allergies), dietary intolerances (e.g. to
lactose containing products), patient preferences
(e.g. vegan patients may refuse products of porcine
origin), religious beliefs, and patients’ knowledge
and understanding of medicines and why they
are being taken (patient beliefs about medicines).
2 . 5 . 2
M E D I C AT I O N R E G I M E N FA C T O R S
Aspects of the prescribed medication regimen that
should be considered during a clinical check include:
I N D I C AT I O N
Ascertain the indication for treatment to check
whether the medicine prescribed is appropriate
for the indication and compatible with
recommended guidelines.
C H A N G E S I N R E G U L A R T R E AT M E N T
Where there are changes in regular therapy
(e.g. strength or dose), you should confirm that
these are intentional.
D O S E , F R E Q U E N C Y A N D S T R E N G T H
You should check that the dose, frequency
and strength of the prescribed medicine are
appropriate – having considered the patient’s
age, renal and hepatic function, weight (and
surface area where appropriate), comorbidities,
concomitant drug treatments and lifestyle pattern.
T H E D O S I N G O F T H E F O R M U L AT I O N
Check that, for the formulation prescribed,
the dose and frequency are appropriate.
D R U G C O M P AT I B I L I T Y
Regular and new therapies should be evaluated
for any clinically significant interactions,
duplications and antagonistic activity.
M O N I T O R I N G R E Q U I R E M E N T S
For medicines that require monitoring, you should
check for the latest test results and ascertain
whether any dose adjustments are required.C O R E C O N C E P T S A N D S K I L L S
2 2 M E P 2 0 1 9
2 . 5 . 3
A D M I N I S T R AT I O N
A N D M O N I T O R I N G
Aspects relating to the administration
and monitoring of a medicine that should be
considered during a clinical check include:
T H E R O U T E O F A D M I N I S T R AT I O N
Check whether the prescribed route of
administration is suitable for the patient and
whether a preparation is available for that route.
Also, check for compatibility issues that may arise
from administering via that route (e.g. due to
co-administration of food or other medicines).
For example, phenytoin can interact with enteral
feeds so administration via an enteral feeding
tube would need to be managed accordingly.
A I D S T O A D M I N I S T R AT I O N
Check whether any aids are required to support
administration. For example, spacer devices, eye
drop devices, Braille or large type or pictogram
labels, additional information sheets or verbal
information and multi-compartment compliance
aids (MCAs).
2 . 5 . 4
R E C O R D K E E P I N G
Record keeping is important for continuity of care,
evidence of the benefit of pharmacy input and
improving patient care. You should make a record
of significant clinical checks, and interventions
made. This should include details of discussions and
agreed decisions with other healthcare professionals.
Depending upon the circumstances it may be
appropriate to make this record in the patient’s
medication record (PMR), an interventions record
book, handover record book or prescription register.
F U R T H E R R E A D I N G
Royal Pharmaceutical Society
Clinical checks – quick reference guide.
www.rpharms.com
Royal Pharmaceutical Society
Professional guidance on the administration
of medicines in healthcare settings. 2019.
www.rpharms.com
Royal Pharmaceutical Society
Quick reference guides (various titles re pharmacy
practice and clinical aspects of pharmacy).
www.rpharms.com
Royal Pharmaceutical Society
Improving patient outcomes through MCA. 2013.
www.rpharms.com
Royal Pharmaceutical Society
Polypharmacy: Getting our medicines right
www.rpharms.com
Avery AJ, Barber N, et al (archived)
Investigating the prevalence and causes
of prescribing errors in general practice:
The PRACtICe Study. 2012.
www.gmc-uk.org/about/what-we-do-and-why/
data-and-research/research-and-insight-archive/
investigating-the-prevalence-and-causes-ofprescribing-errors-in-general-practice
Avery AJ, Rodgers S, et al
Pharmacist-led information technology enabled
intervention for reducing medication errors:
Multicentre cluster randomised controlled trial
and cost effectiveness analysis (PINCER Trial).
The Lancet; Vol 379, Issue 9823, April 07 2012.
www.thelancet.com/journals/lancet/article/
PIIS0140-6736(11)61817-5/fulltext
British National Formulary
www.medicinescomplete.com
or www.evidence.nhs.uk
British National Formulary for Children
www.medicinescomplete.com
or www.evidence.nhs.uk
Clinical Pharmacist
www.pharmaceutical-journal.com/publications/
clinical-pharmacist
Dornan T, Ashcroft D, et al
An in depth investigation into causes of prescribing
errors by foundation trainees in relation to their
medical education. EQUIP Study. 2009.
www.gmc-uk.org (search EQUIP study)
General Pharmaceutical Council (GPhC)
Guidance on consent. 2018.
www.pharmacyregulation.org
(see MEP Appendix 4)
Gray AH, Wright J, et al
Clinical Pharmacy Pocket Companion (2nd edition).
2015. London; Pharmaceutical Press.
www.pharmpress.comC O R E C O N C E P T S A N D S K I L L S
M E P 2 0 1 9 23
2.6
The pharmacist
consultation in
practice
2 . 6 . 1 M E D I C I N E R E C O N C I L I AT I O N
2 . 6 . 2 H E L P I N G PAT I E N T S T O
U N D E R S TA N D T H E I R M E D I C I N E
A pharmacist consultation is any discussion
between a pharmacist and a patient and is an
essential part of providing patient-centred care in
practice. Patients should be encouraged to engage
in the consultation to ensure that it is a two-way
discussion where they can share their views and be
involved in decision-making around their treatment.
The Consultation Skills Assessment (also known as
the Medication Related Consultation Framework)
is one of the Foundation Pharmacy Framework
tools and can be used to assess and demonstrate
your consultation behaviours and skills. Further
information can be found in the Foundation
programme area on the RPS website:
www.rpharms.com/professionalp-development/
foundation-programme
2 . 6 . 1
M E D I C I N E S R E C O N C I L I AT I O N
Medicines reconciliation is the process of
identifying an accurate list of a patient’s current
medicines (including over-the-counter and
complementary medicines) and carrying out
a comparison of these with the current list in use,
recognising any discrepancies, and documenting
any changes. It also takes into account the
current health of the patient and any active or
long-standing issues. The result is a complete list
of medicines that is then accurately
communicated. The pharmacist who is carrying
out medicines reconciliation should ensure that
any discrepancies are resolved by highlighting
these and working with relevant members of the
multidisciplinary team. The pharmacist should
also keep the patient informed.
Medicines reconciliation should take place
whenever patients are transferred from one
care setting to another, when they are admitted
to hospital, transferred between wards and on
discharge. The way that the process is carried
out will vary between care settings.
Further information on medicines reconciliation
in different settings can be found in NICE Guideline
Medicines optimisation: the safe and effective use
of medicines to enable the best possible outcomes:
www.nice.org.uk/guidance/ng5
Accurate medicines reconciliation prevents
medication errors and provides a foundation
for assessing the appropriateness of a patient’s
current medicines and directing future treatment
choices to ensure that the patient receive the best
care. The process also allows other pharmaceutical
issues such as poor adherence or non-adherence
to be identified.
S O U R C E S O F I N F O R M AT I O N
Sources of information that may be used when
carrying out medicines reconciliation include:
1 Patient or patient’s representative
2 Patient’s medicines
3 Repeat prescriptions
4 GP referral letters
5 The patient’s GP surgery
6 Hospital discharge summaries or outpatient
appointment notes
7 Community pharmacy patient medication
records
8 Care home records
9 Drug treatment centre records
10 Other healthcare professionals and specialist
clinics
11 Patient medical records where available
(e.g. in prisons or the Emergency Care Summary
(Scotland), Summary Care Record (England),
or Welsh GP Record (see also section 2.5)
Stephens M
Hospital Pharmacy (2nd edition). 2011.
London; Pharmaceutical Press.
www.pharmpress.comC O R E C O N C E P T S A N D S K I L L S
24 M E P 2 0 1 9
G E N E R A L T I P S F O R
O B TA I N I N G A M E D I C AT I O N
H I S T O R Y F R O M A PAT I E N T
• Explain to the patient why the history
is being taken
• Use a balance of open-ended questions
(e.g. what, how, why, when) with closed
questions (i.e. those requiring yes/no answers)
• Avoid jargon – keep it simple
• Clarify vague responses with further questioning
or by using other sources of information
• Keep the patient at ease
K E Y P O I N T S
A R E T H E S O U R C E S Y O U U S E
U P -T O - D AT E ?
Aim to use the most complete, reliable and
up-to-date source(s) of information.
C R O S S - C H E C K A D H E R E N C E
Medication histories should be cross-checked
against different sources and confirmed with the
patient or patient’s representative. The medicines
they are actually taking, and how they are taking
them, may differ from written documentation
(e.g. the prescribing record held by the patient’s GP).
N O N - D A I LY M E D I C I N E S
Remember to ask patients whether they take any
medicines ‘when required‘ (e.g. reliever inhalers)
,or on certain days of the week. Also remember
to ask about the sorts of formulations that might
be forgotten (e.g. nasal sprays, eye or ear drops,
ointments, depot injections, patches, etc.).
Patients may also need prompting to remember
medicines such as oral contraceptives and
hormone replacement therapy.
H I S T O R I C A L M E D I C I N E S
The medication history should not be restricted
to current therapies but should include any recently
stopped or changed medicines.
S E L F - S E L E C T E D M E D I C I N E S
Include any medicinal product that the patient
is taking – whether prescribed or not – and do
not restrict the medication history to medicines
obtained on prescription. Over-the-counter (OTC)
medicines, herbal products, vitamins, dietary
supplements, recreational drugs (e.g. alcohol
and tobacco) and remedies purchased over
the internet should also be included.
W H AT I N F O R M AT I O N
S H O U L D I O B TA I N W H E N
TA K I N G A M E D I C AT I O N
H I S T O R Y ?
For each medicine, the following should
be determined:
• Generic name of the drug
• Brand name of the drug, where appropriate
(for example, where bioavailability variations
between brands can have clinical consequences,
such as lithium therapy)
• Dose – both the prescribed dose and the actual
dose the patient is taking (NB: This may best be
described to the patient as a quantity of tablets
rather than as milligrams of active ingredient)
• Strength of the medicine taken
• Formulation used (e.g. phenytoin – 100mg
as a liquid does not deliver the same dose
as a 100mg tablet)
• Route of administration (this could be an unlicensed
route – e.g. ciprofloxacin eye drops for the ear)
• Frequency of administration – this should include
the time of administration for certain medicines
(e.g. levodopa)
• Length of therapy, if appropriate (e.g. for antibiotics)
• Administration device and brand for injectables
(e.g. insulin)
• Day or date of administration for medicines taken
on specific days of the week or month
F U R T H E R R E A D I N G
Royal Pharmaceutical Society
Medication history – quick reference guide. 2011.
www.rpharms.com
East and South East England Specialist
Pharmacy Services
Medicines reconciliation: Best practice
resource and toolkit. 2015.
www.sps.nhs.ukC O R E C O N C E P T S A N D S K I L L S
M E P 2 0 1 9 25
Healthcare Improvement Scotland
Medicines reconciliation care bundle. 2015.
www.ihub.scot
National Institute for Health and Care
Excellence (NICE)
Medicines optimisation. Quality standard. 2016.
www.nice.org.uk
National Institute for Health and Care
Excellence (NICE)
Medicines optimisation: the safe and effective
use of medicines to enable the best possible
outcomes. NICE guideline. 2015.
www.nice.org.uk
Stephens M.
Hospital Pharmacy (2nd edition). 2011.
London; Pharmaceutical Press.
www.pharmpress.com
2 . 6 . 2
H E L P I N G PAT I E N T S T O
U N D E R S TA N D T H E I R M E D I C I N E S
An important key role of pharmacists is ensuring
that patients understand their medicines, the
role that they play in maintaining their wellbeing
and to empower patients to use these safely and
effectively to get the most from their treatment.
Providing information for patients on their
medicines involves being able to build a rapport
with the patient, having good communication skills,
empathy, being able to put the patient at ease and
being able to confer an understanding and belief
that the health of the patient is important to the
pharmacist. Involving and engaging the patient
in this process is essential in ensuring that the
pharmacist-patient relationship is concordant.
O P P O R T U N I T I E S F O R H E L P I N G
PAT I E N T S U N D E R S TA N D
T H E I R M E D I C I N E S
Consultations should not be limited to when
a supply of newly prescribed medicines is made,
and almost any interaction with the patient can
be used as an opportunity to help them understand
their medicines. A simple question asking,
“How are you getting on with your medicines?”
can often be a successful engaging starting point.
Illustrative examples of opportunities include:
• Point of sale for over-the-counter medicines
• Any medication reviews
• Diagnostic testing and screening
• Patient group directions
• Minor ailment schemes
• Whilst taking medication history
• During a hospital stay
• Point of discharge
• Outpatient clinics
• When a change has been made
to a current medicine
• Point of a supply of a regular prescription
A D V I C E F O R S U C C E S S F U L
PAT I E N T C O N S U LTAT I O N S
• Try to understand the level of existing knowledge,
understanding and concerns the patient
has regarding their medicines. Consider any
misunderstandings which could be a barrier to
adherence. Explore what the patient has already
been told about their medicines, whether there
are any concerns and what the patient’s
expectations are
• Ensure you are familiar with the medicines you
will be providing counselling on and any additional
information that is relevant to those medicines.
If in doubt, take time to review and re-familiarise
yourself with the medicine. For example – look
out for interactions with other medicines, food,
or supplements, or medicines with common or
significant side effects, complex administration
regimens, special storage requirements, or narrow
therapeutic index. Check standard references
(e.g. BNF or national guidelines for additional
patient and carer advice)
• Aim for a structured approach and tailor the
language and level of detail used to the patient.
The format that is appropriate will depend upon
both patient characteristics and the medicines
that are taken. As an illustration, the patient may
be knowledgeable about their medicines and
condition, for example as a result of caring for
a family member with the same conditionC O R E C O N C E P T S A N D S K I L L S
26 M E P 2 0 1 9
• Where appropriate use different methods
of communication to support your discussions
such as pictograms and medication cards
• Respect patient privacy and ensure
that confidentiality is protected
• Ensure that the process is two-way and
interactive, not simply a list of facts about
medicines. There should be opportunities
for questions and discussion.
• As a minimum, you should consider discussing
the following points:
• What is the medicine and why has it been
prescribed? How does it impact upon the
medical condition and how does it alleviate
the symptoms? e.g. This is a blood pressure
medicine which should lower your blood
pressure to normal levels which will help
prevent further complications
• How and when to take the medicine
• How much to take and what to expect,
e.g. antibiotics need to be taken regularly
and the course completed even after
symptoms subside
• What to do if the patient misses a dose
• What are the likely side effects and how
to manage them
• If applicable, any lifestyle or dietary
changes that need to be made or that
can affect the treatment
• Additional information relating to storage
requirements, expiry dates, disposal and
monitoring requirements can also be
included where appropriate
• Check patient understanding by asking
them to describe back to you the key
information you have provided.
F U R T H E R R E A D I N G
Royal Pharmaceutical Society
Counselling patients on medicines –
quick reference guide.
www.rpharms.com
Royal Pharmaceutical Society
Medication review – quick reference guide.
www.rpharms.com
Royal Pharmaceutical Society
Medicines adherence – quick reference guide.
www.rpharms.com
Royal Pharmaceutical Society
Polypharmacy: Getting our medicines right
www.rpharms.com
CPPE and NHS Health Education England
Consultation skills for pharmacy practice:
practice standards for England.
www.consultationskillsforpharmacy.com
(endorsed by the RPS)
Health Education and Improvement Wales
Various training resources available.
www.wcppe.org.uk
National Institute for Health and Care Excellence
Medicines adherence: Involving patients in
decisions about prescribed medicines and
supporting adherence. Clinical guideline. 2009.
www.nice.org.uk
NHS Education for Scotland
Patient-centred consultation skills training
(one-day training course).
www.nes.scot.nhs.uk
2.7
Getting the
culture right
2 . 7. 1 A J U S T C U LT U R E
“In the end, culture will trump rules, standards
and control strategies every single time.”
Professor Donald Berwick
A promise to learn – a commitment to act (2013)
We know that it is important for the profession
to get the culture right. There have been infamous
examples across industries and organisations
of the problems caused by the wrong culture,
including within the banking industry, the media
and within healthcare. The wrong type of culture
contributed to the unacceptable failings
at Mid-Staffordshire NHS Foundation Trust hospital
between 2005 and 2008, those at Orchid View
care home and also the abuse at Winterbourne
View private hospital.C O R E C O N C E P T S A N D S K I L L S
M E P 2 0 1 9 2 7
The types of culture which collectively help us
to achieve patient-centred, safe and effective
care together with professional empowerment are
interlinked and include a culture that is based upon
the principles and values of fairness, quality, safety,
transparency, learning and reporting.
Underpinning getting the culture right is
a ‘just culture’. This is a culture based upon
fairness and is achieved when attitudes,
behaviours and practices are fair
