Main results
This comprehensive picture of UK critical care pharmacy workforce shows that the quantity of pharmacy provision has significantly increased since 2015 [
13]. Progress has been made on time spent across all three broad categories of activity—independent patient review, multiprofessional ward round participation, and professional support activities (e.g., clinical governance, teaching, service improvement). Almost three-quarters of critical care units now have access to clinical pharmacists with the required minimum level of critical care competence, and a high proportion of critical care pharmacists are prescribers.
Continuity of care arrangements have marginally improved since 2015, with fewer untrained pharmacists being utilised, and fewer units reporting no cover is provided. The highest available competence level in the organisation is very similar to the position in 2015. However, most critical care pharmacy services still fall below minimum standards for weekday services, and disappointing progress made with respect to weekend services.
These results are underpinned by an excellent response rate of 96%, with data now captured to the level of ‘critical care unit’, rather than per organisation. Self-reporting of pharmacist competence level remains a limitation, although consistency in methodology enables direct comparison with historical workforce data [
13].
These UK critical care pharmacist workforce results display some commonality with workforce data from the United States of America (USA) [
20,
21]. In Newsome’s USA report [
20], the majority of participants (76%) expressed a need for additional critical care pharmacists at their institutions. UK data compares favourably with US workforce data with nearly all UK units having clinical pharmacist services, compared to approximately 70% in USA ICUs [
21]. Direct comparison with Canadian critical care pharmacist availability data was not possible due to differences in response rate and survey questions [
22].
Greater awareness of national standards [
7], the introduction of an NHS England commissioning document for critical care services [
8], and NHS Scotland standards [
23], in a pre-pandemic landscape, may have contributed to a climate of investment in critical care pharmacists. These standards are based on an appreciation of the benefits for patient outcomes that come from improvements in the quality and medication safety clinical pharmacists bring to critical care multiprofessional team working [
3]. Nevertheless, for these medicines optimisation roles to be delivered, the required resources need to be in place. Poorly resourced units limit activity to identifying medication errors [
4]. Similarly, in the USA workforce survey [
20], clinical pharmacists perceived that higher patient: pharmacist ratios led to unsafe patient care, and clinical pharmacist understaffing may be a factor in burnout [
24]. Moreover, lack of service continuity for periods of leave and weekends may be a stressor, particularly to pharmacists in critical care [
25]. More understanding of burnout syndrome risks and the impact on workforce recruitment and retention is required for UK clinical pharmacy professionals.
The increased activity by critical care pharmacists in attending the multiprofessional ward round is welcomed. The ward round facilitates contributions of pharmacists to patients care, e.g., reducing patient adverse drug events [
26]. Multiprofessional ward rounds have benefits for team working and co-ordination [
27] that are associated with improved patient outcomes [
28]. Multiprofessional rounds support effective team working, dependability and task allocation, emphasising that single professions and roles in critical care areas should not be considered in isolation and appropriate co-ordination of tasks is required in such a high-intensity, clinically unpredictable and acute care area [
29].
Progression in the proportion of advanced-level pharmacists (ASii) is a welcome finding. Effective systems in patient safety require not only the availability of key healthcare professionals, but those with the right level of training. The combined availability of pharmacists practising at a higher level contributes to improved medicines optimisation outputs [
4,
30]. Similarly, more advanced practice as implied by independent pharmacist prescribing [
31], is available on the majority of critical care units. This prescribing role availability compare very favourably with US data [
21], and is in line with previous projections for UK critical care prescribing capability [
10].
However, some NHS regions have approximately half the median weekday provision of other regions. The overall gap across the UK is 203 wte pharmacists to meet minimum weekday standards. In absolute numbers, this is not a large number of posts, for comparison there are at least 17,615 wte nurses in critical care in England and Wales [
32], however this deficit represents 6 posts for every 10 critical care units in the UK.
Only a minority of pharmacist posts are funded by critical care departments, with the majority still funded by pharmacy departments. Such a disparate and uncoordinated funding model makes it difficult to prioritise service resourcing and provision and makes the critical care provision vulnerable to intra-departmental differences in service vision and goals. Pharmacy managers have conflicting priorities related to medicines optimisation dashboards, e.g., requiring a staff deployment focus on clinical areas with high volumes of patient turn-over, to meet basic operational performance indicators such as medicine reconciliation and patient discharges, within limited resource. This is particularly true when tackling weekend services [
33].
The lack of progress in weekend service provision remains a concern. In the USA, weekend services were less common than weekday services, although many activities still had much better provision than in the UK [
21], with greater than 50% availability in key areas such as evaluating /monitoring drug therapy, pharmacokinetic monitoring, and formal pharmacotherapy consults. Only 2.7% of all UK critical care pharmacists time is deployed at weekends, it is very unlikely that UK pharmacists have sufficient job time available to match the extent of weekend activities reported in the USA. This is despite data demonstrating a significant increase in the rate of critical care pharmacist interventions on a Monday compared to the rest of the week, and a higher rate of contributions on weekends in those services that do maintain a weekend service [
30].
Unlike in the USA [
34], the UK does not yet have a recognised critical care pharmacist training programme. The need for [
35], and format of [
9], an advanced-level training programme for critical care pharmacists has been identified, but national delivery and credentialling remains a challenge. Greater organisational workstream alignment between pharmacy bodies and intensive care specialty groups can aid pharmacy service developments. An example from the UK is pharmacist membership of the Faculty of Intensive Care Medicine [
36]. This recent development is in recognition of the mutual benefits of closer multiprofessional group working and opportunities such as the acceleration of advanced-level practice for clinical pharmacists in the specialty.
Standards of practice described for UK critical care pharmacists are commensurate with statements in other territories, such as Australia and New Zealand [
6], and the USA [
37]. Standards in the USA are long established and have recently been updated, although implementation is variable [
20]. Standards in Australia [
6] are strongly endorsed by the College of Intensive Care Medicine of Australia and New Zealand [
38]. The implications for the clinical pharmacy workforce, including the need for training and recognition, are highlighted [
39]. To address the workforce challenge, a step-change in critical care pharmacist funding, training and workforce modelling is required at a national level. Indeed, this vision has been captured in the recent recommendation for a national costed model for critical care pharmacists in England, to support investment in critical care pharmacists to benefit services and patient care [
40]. Nevertheless, the overall effect of critical care pharmacy workforce shortages, in addition to those of medical and nursing staff, on patient safety and care quality provision was not explicit [
40]. This will require the input of national health bodies to co-ordinate a strategy review and action plan, and possibly needs to be driven by the specialty in its wider sense, rather than pharmacy on its own. This national work must include further research into the extent and risk factors for burnout syndrome for clinical pharmacy professionals working in critical care areas.