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P36 Streamlining the paediatric pharmacy rheumatology methotrexate monitoring and prescription service
  1. Lo Alice
  1. Barts Health NHS Trust


NHS providers and commissioners ended 2015/2016 with a deficit of £1.85 billion – the largest aggregate deficit in NHS history. One option is to meet this deficit is to improve productivity delivering better value care to help the NHS meet its efficiency targets.1 This is supported by the Carter Report where it stated that pharmacists and clinical pharmacy technicians to spend much more time on clinical pharmacy services than on infrastructure activities or back-office services.2

Aim The aim was to improve the efficiency and cost effectiveness of the paediatric rheumatology service for methotrexate patients requiring therapeutic drug monitoring (TDM) by assigning tasks according to skill mix.

Method Value stream mapping (VSM), a lean methodology analysing the current state of a process through work flow mapping and designing a future state for the process in order to improve the process. This was used by the pharmacist and consultant to review the paediatric pharmacy rheumatology patient flow. Each step was determined then reviewed for value to patient care and assigned to the consultant, pharmacist or patient care co-ordinator (PCC) according to skill mix.3

Results 18 different processes were mapped for monitoring a new and current patient’s blood test results and homecare supply. For a new patient registration 5 steps were involved, 8 steps for monitoring a patient’s blood results and 5 steps for homecare supply. In addition, the pharmacist attended the rheumatology clinics when methotrexate patients were booked in. This involved approximately 2 hours every 2 weeks, taking into account that clinics usually did not run on time, to see between 1–3 patients. After VSM it was agreed the consultant would contact the pharmacist when there is a new patient or a current patient requires review. Previously the pharmacist was responsible for contacting patients/parents and carers to remind them of overdue blood tests taking around 45 min a week. With VSM the PCC was identified as the best person to do this. On a weekly basis the pharmacist will access the TDM database and update a list of patients that was overdue blood tests. This list is sent to the consultant and PCC. The PCC will contact the families and update the list with outcomes. Homecare prescriptions were previously organised by the pharmacist for the consultant to sign. The pharmacist continues to ensure the prescriptions are correct in terms of need for supply (liaison with the homecare company, medical documents and consultant for clinical need) and dosage but the PCC liaising with the consultant for administration purposes such as printing of prescriptions and returning prescriptions back to the pharmacist. A standard operating procedure was written to ensure roles and responsibilities are clear.

Conclusion This simple and quick exercise has improved the efficiency and cost effectiveness of the service as the most appropriate person now actions each step. Having access to a PCC has saved the pharmacist approximately 1 hour a week and the consultant clinic referral system approximately 2 hours twice a month equating to over 1.5 working days a month.


  1. Dunn P, McKenna H, Murray R. Deficits in the NHS 2016. The Kings Fund available at (Accessed 12.12.17).

  2. Lord Carter of Coles. Operational productivity and performance in English NHS acute hospitals: Unwarranted variations. Department of Health. London. Available at (Accessed 12.12.17).

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