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Independent reviewers have prescribed a major cultural reset for the General Hospital's Pharmacy after finding that staff felt unsupported and that some had apparently faced "punitive measures" for taking sick days, leading them to occasionally come into work even when feeling unwell.
Martin Keble and Phil Southworth, NHS Chief and Deputy Chief Pharmacists respectively, have made dozens of recommendations in their ‘Jersey General Hospital Pharmacy Review’ which was carried out last month at the invitation of Health.
Their comments painted the picture of a workforce that was strained, stressed and "dismissed" by senior managers, carrying out operations within "cramped" spaces and an "unjust culture" that was the result of "longstanding" issues within the department.
It also made note of external pressures (such as global medication shortages) and lengthy queues which have been plaguing the Pharmacy for months, and have been the target of much media attention.
In a departure from usual protocol which would see official reviews shared via the Health Advisory Board and/or Government communications staff, Health Minister Tom Binet shared the review directly with journalists on Wednesday afternoon.
He said he had chosen to "change the usual process" of waiting for a formal submission to be made to the next Health Advisory Board meeting and make the review public now. This decision came only after he analysed the report to ensure that it did not compromise patient or staff confidentiality.
Carried out in the first half of June and dated 7 July, the review includes the views of current and former Hospital Pharmacy staff, senior management and the Health Minister, all of whom met with reviewers, who spent three days conducting interviews and workshops with both pharmacy staff and external stakeholders.
Pictured: Deputy Binet said he had changed the "usual process" by sending the report directly to media.
More than 25 hours of face-to-face feedback was received from over 30 members of the department.
Deputy Binet said since receiving the report (the Health Advisory Board have also received a copy), hospital pharmacists have been made aware of the findings, and an "Action Plan" is now in development. This will be submitted to the Health Advisory Board in September, he said.
Deputy Binet added: "This review is the latest in our ongoing programme of work to improve patient care across the entire health department.
"Improvements were already being made whilst this review was taking place, some of which resulted in reducing the queues to collect prescriptions at the hospital.
"Other changes will also be taken forward whilst the action plan is being completed."
In the review, 54 short, medium, and long-term recommendations were made, encompassing culture, workforce, workload, education and training.
Among the headline recommendations was the insistence from reviewers that consultants should cease prescribing for private patients – these prescriptions should instead be taken to community pharmacies.
Lack of strategic direction when it came to pharmacy, medicines and training was also cited as a problem.
Milestones and targets in the short, medium, and long term, were non-existent – and this omission should be solved with a strategy co-produced through staff engagement and involve regular monitoring of progress.
"This is a priority," said the reviewers, who were asked to come into the pharmacy department as "fresh pairs of eyes". The department could then use the strategy as an opportunity to "agree a way of resetting the culture for the department".
"Collaboration with other hospitals across the Channel Islands may offer some efficiencies in aspects of the pharmacy services provided," it added.
Developing those relationships could help with resilience of the services that pharmacy offer, and work to develop this collaboration has started but is at an early stage.
Cultural issues are not new within Health, and have been the subject of several reports and reviews in past, including a much-cited report by Professor Hugo Mascie-Taylor which found serious issues with governance at the Hospital.
More recently, senior consultants brought in to drive improvements in the health service last month delivered damning post-mortems of their experience, including parting shots at the attitude of consultants and cultural problems.
Pictured: The Mascie-Taylor report exposed cultural issues within the department.
The two pharmacy reviewers said that staff "showed signs of being upset and angry at the previous and current position including with leadership teams", with some "sceptical" that this review would effect change and "nothing changed from the others".
"Based on the information seen and heard in the review it was felt by the reviewers that the issues described had not acutely developed over the past few years, but were more longstanding," the report said, before adding: "More recently though, staff felt that the situation was not improving, instead getting worse leading to the current scenario in the department.
Staff said they felt "dismissed" or "not listened to by senior managers" when trying to raise concerns or suggest ideas for improvement, and there was "unjust culture with confidential information sometimes shared and HR policies not being followed regularly", it said – all of which had resulted in "feelings of not being able to speak up or listened to", and some situations where concerns were raised to the 'Freedom To Speak Up' Guardians.
"They also felt there was an overall lack of communication and poor visibility of senior leaders within the department," it added.
Staff reported "punitive measures" being in place if they were off sick, being "sickness managed" and therefore came to work on occasions when they did not feel well.
A culture of 'keeping things within pharmacy' and a reluctance for issues and concerns to be highlighted or discussed outside of the pharmacy department were also cited.
The reviewers recommended, before six months are up, to focus on developing an open culture of continuous improvement where staff are empowered to shape the culture of the department, and the services it provides.
A "monthly coffee" with the Chief Pharmacist should also be introduced for all new starters and any other staff.
Within 12 months, the reviewers want to see a monthly 'Improvement Board' introduced for all staff, where representatives from across the pharmacy department meet to discuss, review, and implement improvement ideas.
An innovative 'You said, we did' approach to feedback from staff surveys should be implemented to ensure staff see action on feedback.
The reviewers also recommended a major restructuring of the department which would see the Chief Pharmacist's role split up and shared among other senior members.
This individual has previously been expected "to lead and manage the hospital service as well as the external pharmacy demands described above", the reviewers said. "This is not manageable and is likely to have contributed to some of the issues described throughout this report."
They said the transition to "divide the historic demands of this role" into separate roles is a "sensible, albeit overdue, approach" to ensure the appropriate senior leadership roles are in place for the Island – while keeping in mind that the scale of the department accurately reflects the overarching size of the population.
Recommended changes include removing the deputy chief pharmaceutical post as well as changing some lines of reporting and renaming certain roles.
It also recommends introducing junior to senior progressions posts for pharmacists and that the consultant pharmacist for mental health should sit in this structure to be able to support clinical activities where necessary.
A lead digital pharmacist and technician are both required as a minimum to support digitalisation requirements of HCS, as well as investment in haemotology and oncology pharmacists.
To help ease pressures that other members of staff were reporting, the reviewers recommended boosting the numbers of posts. Easing these pressures would also be helped by temporarily employing remote agency workers that can help reduce the operational burden of staff onsite.
The reviewers were clear that locum staff would not "replace" on-site staff but could deliver "significant parts of the workload that releases them to focus on appropriate activities".
Leaving interviews should also be organised for all staff, with feedback provided to managers and focus should be made to "increase the pipeline of future staff".
The report makes stressful reading and describes the dispensary as a "cramped environment" with a "complex system" of 22 places to look for prescriptions, "unnecessary delays" and more.
More staffing is needed to manage these workload stresses, including three pharmacy receptionists, and reviewing the operations in the dispensary, the report said.
It also recommended that the pharmacy should stop dispensing of all private prescriptions.
Longer-term, the department should review and increase the medicines that GPs can prescribe to reduce the workload further.
The reviewers found there was no strategy for education or training staff in the department, as well as a lack of supervision and constructive feedback during trainee placements.
The only sessions which have been undertaken were on the topic of "resilience" but staff "were not positive about the sessions in terms of time out of the busy day attending" and "found very limited value from the tools and techniques provided with the sessions", the report said.
"There has been a lack of management development, and resilience, within the department," it added.
"It is possible that this is a result of significant challenge put on managers by successive senior managers, leading to breakdown, resignation, or refusal to apply for managerial roles."
The reviewers recommended developing an education and training strategy for all staff groups within a year.
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