It’s never been a more challenging time to work in the NHS as staff across the board contend with a lack of resources and a desperate need to recruit and retain more staff amid burnout, early retirement, and opportunities abroad.

A new series spotlighting people working on the frontline of an increasingly-stretched NHS in Scotland, facing increased demands compounded by budget cuts and understaffing, will explore the highs and lows of working in Scotland’s health service.

In the first of this series, healthandcare.scot heard from an NHS hospital pharmacist about the challenges faced, the benefits of working in diverse close-knit teams and how action on the workforce crisis will help patients and staff alike.

Rotating across various specialities from care of the elderly to medical and surgical specialities, Hannah the pharmacist* works in one of NHS Scotland’s busiest city hospitals.

The bulk of her work involves reviewing patients on admission to assess the appropriateness of medicines, and then ensuring treatments are transferred and advising on the safety of a patient’s medicines throughout their stay in hospital:

“A lot of it is behind the scenes – a lot of advising the doctors on interactions, dose adjustments, treatment options and so on. We do have a patient-facing role without a doubt: we counsel patients, we discuss their records with them.

“I would say some of my most important interventions, the patient will never know about. Patients get the benefit of our input for example, if I advise on a dose adjustment to support their renal function – what matters is they get the benefit of a safer treatment plan.”

As part of wider care planning, Hannah explains another big part of her job with the bed crisis is facilitating timely discharges for patients.

Multidisciplinary work

Hannah says one huge positive for hospital pharmacists, unlike in community pharmacy, is the wider multidisciplinary teams that they get to work within to integrate care. Pharmacists work together with nurses, doctors, physios, dieticians for the benefit of all patients:

“It’s amazing, even from a learning and development point of view. You learn so much from senior doctors who teach day in day out; we learn, we’re supported by them. Having that team to bounce off for decisions and support, and also just to be part of a team at work – it’s great.

“I think the more multidisciplinary team working, the more colleagues can share and learn from each other and the better it is for patients.”

Working as a pharmacist on hospital wards means reviewing patients daily is essential to their work – and, as with other healthcare staff facing increased workloads, Scotland’s pharmacists triage patients:

“We attend ward rounds with the consultants and review patients daily. We triage patients – we’ve got our high-risk patients that we see every day, patients that we don’t need to see again until discharge and patients that we see every other day.

“There should be one pharmacist to see every two wards, and we’re covering anywhere between 30-60 patients so we need to prioritise our workload. Between all that, we’re sorting our discharges.”

To do this, Hannah assesses clinical appropriateness of doses, changes in patients’ condition, or additional needs for patients to go home – considering whether one medication started in hospital must be continued or stopped.

Hannah says for some patients she will also counsel them through their medicines’ regime – the how, when and why of their prescriptions.

However, she adds that priorities have shifted to getting patients safe to leave out of hospital as quickly as possible to free up space for those waiting to be admitted.

Workforce crisis

In February, Audit Scotland laid bare unprecedented financial and operational challenges within the NHS, prompting a number of medical and nursing unions to call for the for urgent improvements to NHS Scotland workforce planning.

From Hannah’s perspective, the workforce crisis plays out in the day-to-day care and management of patients in hospital and those leaving, against the backdrop of hospitals operating near to or at capacity:

“A lot of it has been just kind of fighting fires – there’s obviously a massive bed crisis. As of recently, we’re covering more wards than we used to which means covering more discharges. We’re not always getting to review patients on the ward and sometimes we are just fighting fires and doing the discharge.

“If we’re not reviewing patients, we don’t always know are there potentially things that are unsafe happening – which is stressful. Obviously, we do have a good relationship with the nurses and the medical staff who are on the wards, and I do trust that they’ll come to us if there is a pressing issue.”

When there’s not time for full clinical reviews, including visiting patients on wards, Hannah says adopting a “professional screen” – looking at the list of medicines and the patients’ condition to check for any glaring interactions.

The emotional impact

Through a heavy sigh, Hannah adds that the workforce crisis is the biggest challenge of working in the NHS – with a culture of relying on goodwill:

“It feels like there was a good bit of recognition throughout the pandemic of what people were doing – and that’s been kind of dropped. We need to retain our staff somehow, and we need to treat them better.”

Continuing, she says the need to support staff beyond clapping or paying lip service is not just for staff benefit, but patients too:

“Obviously there’s staffing issues and I think that’s the biggest issue now. We’ve got more work for no more pay and with no more time. And we care about patients and, when we can’t see people, emotionally that’s tough.

“On top of being stressed at work because you can’t really complete your workload, or you’ve got more to do, but the fact that you feel like sometimes you can’t provide the same level of patient care that you could do when you had your top level of staff, it’s tough – it’s really tough.”

Stressing that this is not an issue for pharmacy alone, but permeates throughout every NHS profession, Hannah was hopeful during the pandemic that staff were finally being valued for the work they’d been doing – but says the first pay offer was “a total slap in the face.”

In terms of staff wellbeing, she says:

“Would I feel comfortable asking for support? Probably not, but maybe there would’ve been a great response – I don’t know because I’ve never sought that. If I had too many wards and was struggling with stress at work, who gets that ward? Is it my colleague or do patients not get that same pharmacy cover?

“I’ve not been trained like this; it’s just how I think about things – and that probably goes for a lot of healthcare staff.”

However, Hannah points out that while their management definitely want to help, though whether they have the resources to do so is another question.

Solutions for an NHS in crisis

Hospital pharmacists, Hannah says are generally paid less than their community pharmacy counterparts and explains that pay cannot be ignored in workforce solutions to retaining staff, but career progression is also vital.

From her perspective, the most recent pay offer goes some way to acknowledging the banding issues and the workforce crisis but does not seem to go far enough for senior charge nurses.

Hannah add that the Agenda for Pay banding is “not fair” for multi-disciplinary colleagues and nursing staff are often the most overworked:

“I think pharmacists are pretty well-paid in comparison to other people who are doing a lot more. I’m in a fortunate position myself – I’m definitely feeling the cost-of-living, but I have been able to absorb increased costs.”

More widely, there is a need for better investment and recruitment in social care, Hannah sees patients who “absolutely cannot be discharged” because they need a social worker assessment.

Ultimately, Hannah says she feels supported by colleagues, but she and the rest of her team are overworked:

“It’s rough – there’s definitely highs and lows. A good aspect of being a hospital pharmacist is you’re working in a team; community and sometimes primary care pharmacy is very solo working – very much you make the decision.

“Hospital pharmacy you’ve got teams of maybe 50-100 pharmacists depending on the site, with a really great skill and experience mix.

“But obviously coming out the pandemic – which was a tough time – people are tired, people are overworked… But how do you keep that momentum going?”

*Hannah is a pseudonym to preserve the pharmacist’s anonymity

Read more: Change needed for women in the healthcare workforce; ‘Resounding' rejection of pay offer; Staff shortage concerns in latest MWC reviews; RCN: Staff need to see light at the end of the tunnel; Scots women at the forefront of medical sciences

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