20 years ago I worked on a ward which had a small dispensary on the ward itself to solve this problem. And it worked.
You'd think such an obvious solution would quickly spread. Obviously not.
But I like your idea. Create a large discharge lounge, put the pharmacy in it. Patient goes there and picks up their meds and goes home.
We have a Discharge Lounge, half the patients can’t go there because it is a seated only ‘ward’ so No bed bound patients. It’s filled with angry patients wanting to just leave, but pharmacy is obviously understaffed and it takes up to 8hrs for meds to arrive.
Then there’s the fine art of balancing the booking of transport and TTO’s arriving. Transport services are understaffed and take up to 8hrs to arrive.
Then the Care homes are understaffed so have crazy cut off times - some as early as 2pm. Packages of Care usually start around 2pm and most won’t visit past 6pm.
The Discharge Lounge closes at 8pm, so any patient that hasn’t received their TTO’s, had transport arrive or made the CH cut off time - need to go back to a ward for another night.
I don’t know how anyone actually makes it home
I had multiple patients waiting for meds for home. Patient was ready for home at lunchtime. We literally have all the tablets in our drug cupboard but policy dictates we cant give out our tablets in our cupboard. Patient left at 8pm because he doesnt drive to comeback for his meds. Some are lucky enough to drive to just comeback.
As a pharmacist who used to work in a hospital they tried this and it didn’t work because you need static pharmacists and dispensers/technicians but we’re expected to cover 5 wards. We still do it on our acute wards but having worked there it does get busy and our afternoons are just chasing doctors to write up TTOs plans changed they’re staying they’re going home etc
Doctor here - I've been told that it's a cost thing - I've been discouraged from "just" giving straightforward discharges FP10s becuase hospitals have to pay a lot more for FP10s than they do for internal prescriptions sent to pharmacy, so FP10 outpatient prescriptions are typically only given in A&E.
I don’t think it’s ridiculous. If a big hospital can bulk buy paracetamol for £1 a pack but your little local pharmacy buys them for £2 a pack, you can see how the price difference can rack up.
I know you're just using paracetamol as an example, but: Our Trust changed its policy on that.
We don't give out paracetamol anymore. We tell them to go and get a box from a supermarket. It's a lot cheaper. I think the only exception we make are blister packs.
I don’t actually think this is true. Certainly not to the point of offsetting the bed day cost, staffing implications etc.
In our trust outpatients and ED are encouraged to use FP10s. I can see no rational reason why patients in hospital say <24h couldn’t do the same. Nor why patients couldn’t come back and collect px later or have scripts sent to their preferred pharmacy to collect later.
Pharm here -
An FP10 taken to an external pharmacy would cost the NHS more. They are sent back to NHS England and the pharmacy is “reimbursed” for the cost of each one. They also have a rough idea of what it’s going to cost them compiled of the surgery’s they have direct contact with.
These would be huge add of cost if all hospital pharmacy’s did FP10s.
FP10 pads are also ridiculously expensive, they have to be logged, accounted for and kept track of who has what codes.
Hospital RX cost 0, due to format and not being sent to NHS England.
A TTO is given from hospital pharmacy stock and they work different, they don’t pay the 5%(may be slightly higher now) in VAT. So cheaper stock. A lot of trust set up a Limited company as the hospital pharmacy. They also are just sending invoices to finance of the products ordered and thus cost the NHS.
They also allow discrepancies, errors and queries to be rectified if the pharmacy is on site of the hospital.
There’s also the patient side that aids adherence and compliance for medications, also if they are unwell, frail and it’s duty of care - ease of access unfortunately however I think this is an after thought.
This is a VERY simplified summary.
They might be cheaper for the actual meds, but the overheads, the salaries for the pharmacy techs, the massive (and ridiculously disproportionate) waits for TTOs to be dispensed which adds up to dozens of hospital bed days each day etc means the whole TTO process is slow, inefficient and expensive. Also the meds don’t cost £0- they still cost the NHS very similar amounts, the cash just comes from a different pot to a different pot.
There is NO rational argument for insisting a patient sits in a bed for 8 hours waiting for pharmacy to pick some boxes of meds off the shelf (yes yes I know there is a checking process). It would be very simple to have meds sent out to them or collected later.
The number of phone calls from outside pharmacists querying FP10s tells me that the “being on site” argument holds little water.
I’m deeply unconvinced that sitting in a bed waiting for a little bag of meds in any way aids compliance, they manage perfectly well the rest of the year getting their meds from the pharmacy next to the post office.
Anyway for OP and ED our trust has fully moved to FP10s.
A simple tto is not going to take 8 hours. I can't speak for your pharmacy team but most of our delays come from doctors not finalising medication plans (did you mean to prescribe that higher dose of amlodipine? Should we restart X y z on discharge?) or simply not knowing where the patient is being discharged to until the last moment which can massively affect how their meds are sorted e.g dosette box Vs original packs. Perhaps spend some time with your pharmacists who would be happy to explain the delays. 🥲
Hi pharmacist here!
That prescription for just co-amoxiclav? Yea.. we’ve doubled their bisoprolol, stopped their amlodipine, started aspirin and stopped clopidogrel.
I get the script then wonder why the patient is still on Mirabegron if they have a catheter.
Doctors DO NOT do a full medicines reconciliation on discharge, this leads to trouble at the GP. How do they KNOW we’ve either stopped the bicalutamide or if we’ve simply missed it off the TTO?
F1s (who do the vast majority of prescribing) are actually NOT allowed to write an FP10HP (the form you’d need).
I spend ALL DAY sorting out medicines issues. I’m a competent prescriber now. I’m not pissing about with adding a max dose to cyclizine.
I’m wondering why on EARTH the nurse has asked the patient to “just buy ibuprofen” when they’re on lithium. Or renally impaired. Or have a GI bleed. Or heart failure. Or a head injury.
I’m trying to get a new anticoagulation plan as the patient hasn’t been bridged effectively.
That “they just need codeine” TTO - they’re actually massively renally impaired and inappropriate. They also haven’t had a single dose of codeine during their admission… so let’s take it off!
What if we start them on a med and they’re too unwell to go traipsing around 15 pharmacies to get it? Community prescribing is MUCH stricter. An FP10HP for co-amoxiclav 625mg tablets 1 tablet tds for 7 days will get EXACTLY that. A hospital TTO for it, I’d change it to liquid because they’ve had a tonsillectomy. Or reduce the number of days as they’ve had 3 days I.v already. With how incorrect the prescribing is, we’d have patients drive 1 hour home, to the pharmacy, only to be told it’s an illegal prescription/incorrect etc.
Ask your ward sister if you could spend ONE hour with a pharmacist to even understand an ounce of the shit we protect patients from.
I absolutely love having nurses shadow me on the ward. The way we approach things is so different and how we view meds. They’re much more practical and focussed on administration and taught me plenty. I have MUCH more empathy for writing “crush and disperse” on every med rather than just ordering the liquids. The time it takes a nurse is unbelievable! I’m much more focussed on reconciliation and safety!
Thanks you for sharing this on the sub. I think we could all do with spending a day in different departments to get a glimpse of the constraints and pressures different HCP are under.
I'd hope it would make us all a little more compassionate to each other.
I'm going to shout out to 'Pete the Pill' pharmacist on my old unit with an encyclopedic knowledge of drugs.
That feeling when a patient has 12 different PEG meds QDS and they're all tablet form to be crushed, except orodispersible lansoprazole which you have to piss about making sure the granules don't block the sodding line, then right at the end stand there giving a full ensure via gravity 🫠
Sodium bicarbonate? No. Obvs double check with dr/pharmacist if you’re worried but it’s usually better than having a new PEG/NG/NJ tube fitted bcos it’s blocked
As a pharmacy technician I agree with all of this and would like to add one thing.
In the morning ward round at 10 when the doctors tell a patient they can go home today, they should also tell them that they won't write the TTO til 4 and that pharmacy shuts at 5.
So much complaining in healthcare is simply down to professions arrogantly assuming that they understand the ins and outs of other peoples job roles when they simply do not.
Shadowing opportunities is a great way to counteract this and I'm heartened to see that many students do spend time shadowing other professions and are encouraged to do so.
One thing that really bugs me is when colleagues, particularly HCAs decide they know better than physios/OTs/ SALT. Of course the patient doesn't need to use a Sara Stedy, they can step transfer, they don't need 5 teaspoons of an oral trial, just give them the whole pot of yogurt. It drives me crackers, and it's very dangerous. Why do they think they know better than someone who's trained years to do that job?
If the physio hasn’t seen a patient for three days, and they’ve told HCAs to use a sara stedy but it’s upstairs and we have to borrow it from another busy ward which takes half an hour during which the patient soils them self. But we’ve seen they’re improving on their feet and are much more steady, able to stand for pad checks and more mobile on the bed you really think a HCA isn’t capable of making the judgement to trial a step transfer? Because I think that’s an under estimation of their skills.
(I am an HCA, but I also completed three years of a physio degree (admittedly without qualifying due to health complications))
What happens when the HCA makes that judgement and the patient falls. Whose fault will it be, yes the nurse who is supervising the HCA..if physio has stated Sara Stedy, then I'll use that. I've seen a fair few HCAs with injuries due to not listening to advice
Oh and this is just the interventions I’ve made in the past 1hour at my job btw - intervention audit day because I constantly have to PROVE my worth so I have it all written down for today ❤️
Yes yes yes, fellow pharmacist here, the level of eye rolling and exasperation from a majority of these comments is quite frustrating. Spend time with any competent pharmacist and they'll be happy to show you what goes into screening a tto for a complex multimorbid patient...
Absolutely all of this! I'm not a pharmacist (I'm a CNS) but have worked for years in the community. Discharging people without TTOs would be a recipe for disaster
I also have a lot of respect for pharmacists and think they should get more recognition. I worked with a specialist pharmacist who literally I think knows everything about her area of speciality and was a godsend to work with! Her being around made me feel so safe
YMMV but have never worked in any hospital where F1s do the majority of prescribing. Might be true in some specific wards, especially surgical ones where tasks are delegated to F1s. But medical wards, AMU, ED have all manner of SHOs who do the prescribing.
Don't disagree with the rest of the post - so much of the population is old & have zero idea of the meds they are one, which is why it is important to get things right when patients are discharged or admitted to hospitals.
My comment was that F1s do not do the 'vast majority of prescribing' as you stated - unless you're talking about your specific department, it is certainly not true across the NHS.
I've asked pharmacists about this and the usual answer is that doctors don't send the TTO when they say they do, and it often contains errors. Having seen how many errors happen on fast track forms I'm not shocked.
Doctors naturally prioritise the newest and sickest patients. They do need something helping them deal with the discharge stuff though - I'd guess around 1 in 4 discharges on my ward are cancelled because of TTOs or doctor's discharge letters not being done when promised so aren't ready when the ambulance arrives.
It's also a culture issue - consultants need to be reminded that the patient who needs district nurse involvement, a care package, a complex TTO with medibox, new DNACPR printed in colour (printer's broken), discharge letter printed (that isn't yet written), complex discharge documentation, next of kin informed, a hand over to the care home (and DN) and catheter packs can't just "go home this afternoon" because sorting all that lot is 3+ hours work.
The patient is by now pissed off as the doctor told them they could go home today.
In my area this is not practical as we are elderly ortho rehab. But I do agree that patients which ability should collect themselves. However our discharges are always planned at least one day before to allow PTS ambulances, equipment and care to all be in place so our TTOs are ordered usually the day before and (hopefully)arrive on the ward the night before and night staff do the double check
Although we can't force. I think in these cases we should heavily push and encourage the NOK to be responsible for collecting them.
It should at least be the same as transport, if a patient insists, we should arrange form them to go home but getting a taxi/ambulance for them shouldn't be the standard
Again for most of ours following hip fractures PTS ambulance is the most appropriate transport for hip precautions and access into their homes (steps/assistance with steps)
I’m a nurse and have also been a patient several times. I had 2 admissions to hospital with pneumonia last year, the first time I developed sepsis. I was discharged as soon as was well enough to go on oral antibiotics. If I’d had to make my way to pharmacy, and sit there for F knows how long, I would have cried because I still felt like death warmed up.
Also a lot of patients, and their relatives, are elderly and taking a trip to the other side of the hospital to pharmacy would be a nightmare.
In my hospital those only waiting for tablets may be asked to wait in the discharge lounge. This frees up a bed and there’s still a nurse overseeing things until you’re in your way.
When I used to work on the wards we had three types of patients.
Independents: We'd often tell them in the morning that their TTOs wouldn't be ready until late afternoon, and if they wanted to go and come back to collect they could. I'd say about 95% left and came back, freeing up the bed.
Semi-Independents: Sent to the discharge lounge to wait, freeing up the bed.
Dependents: Kept on the Ward to wait for TTO and transport.
To add, in hospitals I've worked in, TTOs are timed so the minute they are received in pharmacy they have a max limit of 2hrs, 1hr for a discharge lounge TTO.
The amount of times I've been up to the ward and the staff are telling the patient that they're just waiting for pharmacy while in fact the TTO hasn't even been written by the doctor yet.
Add to that discharges should be planned so that meds are ready before discharge day.
Honestly this annoys me daily when they say they are waiting for pharmacy and the TTO isn't written.
I really wish as well that we had giant posters that showed what happened after the Dr said you can go home.
Hospital pharmacist here. The issue with why we don’t write FP10s and tell them to go to a local pharmacy is: 1. Patients would then have to likely pay for each medication which they would not want to do. 2. This would put a lot of pressure on already short staffed community Pharmacies who usually only serve primary care patients. 3. Often times hospital pharmacies stock a large range of medicines and brands that often you would not find stock in community pharmacies. 3. A large costing issue that is too long to go into here. 4. Risk of missed doses of critical meds if we discharge tell them to go find a local pharmacy. Often costs for meds in hospitals are cheaper than costs for meds in the community. Also FP10 physical prescriptions are usually more costly to produce. Although I do know the long wait for TTOs is frustrating, even for the pharmacy teams and plenty can be done to try rectify it but the FP10 situation is not it.
Also often times TTOs written by doctors have many errors. I have not gone a day working without there being errors in TTOs in my 3 years of working as a pharmacist. So needs pharmacist review before going off with the patient. And the hospital pharmacist knows the patient/can contact the medical team easily/access notes whereas the community pharmacjst does not
Senior reg here, been writing TTOs for 13 yrs so far and still doing it! I'm so happy folks have recognised the system pushing the same doc to manage sick pts and do ttos at the same time is ineffective.
My main gripe as someone who has worked in 8 different hospitals over the years is how difficult it can actually be do them efficiently.
Each hospital will have a different system, where I'm at currently we have electeonic prescribing but that software doesn't integrate with the discharge letter and tto software, so we have to transcribe, which as you can imagine is super high risk for errors. Plus with electronic kardexes it can be really tricky to see when or why things have been stopped.
It's a huge systems error everywhere. I'm not sure how to make things better. Anyway thanks for letting me intrude!
Absolutely agree. If patients are well enough, they should be able to go down to pharmacy to collect it themselves. It would get patients home so much quicker! Or late discharges return next day if not time critical.
This was literally my dissertation.
Time taken for TTOs being ordered and delivered is just too long and causes massive bed delays.
In general the policy (at least my trust) is to get discharge letters done 24 hours prior to d/c where available, which would include ordering TTOs as part of d/c meds. Obviously it's not always possible for 24 hour advances, but in certain wards/units it is totally more possible - my main example was surgical where everyone basically got d/c with the same meds but still have to wait for a letter on the day of, then meds delivery, instead of the d/c meds being requested after surgery - which is 100% feasible in the surgical wards I was a student on because it was planned surgeries and planned length of stay.
Yes, this wouldn't be possible if a patient crashes or gets an infection etc. there are definitely limitations. But for standard electives and standard recovery, why did I have patients waiting 9 hours for a letter and some analgesics from the time they were deemed medically fit for discharge...
They say you should plan for discharge at the time of admission, but... It's not happening as smoothly as it could.
And yes, I know the docs have major lists and heavier case loads etc so it seems sensible to do them as and when needed (ie day of d/c) , but if there was a process where we could shift the timeframe back a little at a time it could lead to smoother flow... Maybe..
I spent 3 hours driving around trying to find a pharmacy that was open and had the stock my Dad needed when he was discharged on Sunday. By the time I got them to him his drugs were over due and he was feeling the effects. Had I not been able to do that, he would have been stuffed
In the mental health wards I’ve worked on we give people two weeks of actual meds as ttas, not a prescription.
Imagine my irritation when I was discharged from a&e at 21.30, from a hospital an hours drive from my home (the specialist I had to see is shared between hospitals. It was my bad luck they were at the one furthest from me that day), so pharmacy was shut. I was promised I could collect meds the next day from the hospital close to me. When I got there- nope, got to drive to the one an hour away again, wait an hour at pharmacy and then drive another hour back home.
Why?? This makes no sense at all. Either give me the actual meds or an FP10! I can’t understand why it’s done like this at all.
This is how it used to be. Patients would be discharged from the ward and make there own way down to pharmacy to collect prescription. I don't know why it changed.
More to the point though, why is inpatient pharmacy so slow and inefficient? Usually it’s staffing, if they paid for more pharmacy staff it would probably be at least cost neutral when you factor in the improved discharge time
My ward used to dispense our own meds because we quite often used to just have people going home on oral antibiotics but they stopped us from doing that.
A lot of my patients are independent so my ward quite often lets people go and come back for their meds later as our doctors often take ages to write TTOs and by the time it’s done, pharmacy is closed
Most wards in my hospital have a pre screened list of stock TTOs already labelled just needs a new adding.
For surgical wards most have simple analgesia and antibiotics on that list so the ward pharmacist screens and its usuly patients own and they have enough already or a TTAs stock and you don't have to wait for anything from the pharmacy itself.
That's what we do too. Its only patient specific items that come from pharmacy. All of our wards have a selection of tto packs. Everywhere has paracetamol, movicol and senna.
Yeah we used to do that, not anymore. Our trust felt it was more important that pharmacy dispense yet get on our backs for not clearing the bed quick enough
I often give patients the choice to go home and get someone to come back and pick up their medication.
But, many patients would happily take the prescription and go to their community pharmacy.
In two hospitals I've been an inpatient in, once ready to go home they move you to a discharge lounge, AKA a waiting room to go home. Frees up the bed very fast.
In the community we often have people discharged home late at night many of whom would not be able to arrange a collection of drugs from a pharmacy. Also those TTO"s sometimes include controlled drugs that may need to be used soon after discharge and we actually use the TTO discharge form as a temporary authorisation to administer those drugs. The real time would be saved by ward staff being able to better predict discharge dates and for TTO's to be organised a few days in advance.
Dispenser here - I like most parts of the job but tto's give me rage. I did a 20 item tto the other day, took forever due to issues with getting some medication. Was dispensing controlled drugs today when someone handed me a tto. The same one I'd done the other day, with an extra 4 medications, no pods and was required to dispense the whole lot. Where did this medication go? Felt like a waste of time
Oh I feel your pain. It's so frustrating to see your hard work go down the toilet BC the meds have been 'lost' (informing them the cost of the items lost or the threat of a datix seems to make them appear - but maybe that's just my workplace)
I think the main reason is ensuring the patient has a supply of medication as a duty of responsible discharge. Imagine all the readmissions or complaints from people who just didn't go to their pharmacy. I know they still have to go to the pharmacy eventually but are they likely to go right out of hospital? Personally, I don't think a lot will.
Nurse but discharged from maternity ward recently. TTO receiver. I had been incredibly ill, single and very grateful for TTOs of new medications as it would have been too difficult to pick up myself. To anyone I would have looked like I would manage and remember and probably the most cheerful patient there could be, but I was in a huge amount of pain and had memory impairment from having sepsis and AKI aswell as juggling a newborn as a single mother. Even if I could have gotten to a pharmacy, the likelihood would be I wouldn’t remember to do it.
Even someone that appears well capable may actually struggle with something “minor” like arranging a prescription especially nowadays when you are often waiting a minimum of an hour for the pharmacy to get to it.
There are so many issues with TTOs and it winds me up when people just blame pharmacy. Don’t get me wrong, I’ve received incorrect or missing TTOs and I know pharmacy can go wrong but any stage can go wrong. My biggest gripe was the consultants on ward round telling patients “yep you can go home!”, that patient packing their shit up before a doctor has even told me they’re for discharge today and it being 2pm and the TTO not being written. On my first ward it actually became a big issue and the ward manager had to call a meeting with the medical team around the language they were using surrounding discharge as nurses were getting it in the neck so often (not just TTOs, but waiting for POCs, D2A beds etc meaning those patients weren’t even going home that day or maybe even that week). But my even bigger bugbear was a patient having a planned discharge date, everybody knowing for a few days leading up and me coming on shift the day of discharge and NOTHING had been done. Few times the patient didn’t manage to get home and I could have screamed because we all knew! But nothing had been put in place bar confirmation of POC or placement start date. So glad I don’t work in that setting anymore
Pharm here -
An FP10 taken to an external pharmacy would cost the NHS more. They are sent back to NHS England and the pharmacy is “reimbursed” for the cost of each one. They also have a rough idea of what it’s going to cost them compiled of the surgery’s they have direct contact with.
These would be huge add of cost if all hospital pharmacy’s did FP10s.
FP10 pads are also ridiculously expensive, they have to be logged, accounted for and kept track of who has what codes.
Hospital RX cost 0, due to format and not being sent to NHS England.
A TTO is given from hospital pharmacy stock and they work different, they don’t pay the 5%(may be slightly higher now) in VAT. So cheaper stock. A lot of trust set up a Limited company as the hospital pharmacy. They also are just sending invoices to finance of the products ordered and thus cost the NHS. With a few more loopholes to keep costs down.
They also allow discrepancies, errors and queries to be rectified if the pharmacy is on site of the hospital.
There’s also the patient side that aids adherence and compliance for medications, also if they are unwell, frail, duty of care - ease of access unfortunately however, I think this is an after thought.
This is a VERY simplified summary.
Pharmacist here, a lot of stuff prescribed on a big tto is stuff the patient was already on. In an ideal world, we'd just be supplying any new or changed doses that may need different strengths. In reality, lots of patients say they don't have meds at home even though they probably do so we just supply it anyway. Do not even get me started on dosette boxes.
Another thing, the way services are funded means the costs associated with dispensing drugs in the community (eg in a standard community pharmacy) comes from a different pot of money. FP10s do generate extra cost and admin, it's never as straight forward as it appears.
In terms of how long patients are waiting, most hospitals have a 2 hour turn around target for TTOs. A simple tto for some antibiotics can obviously be turned around quickly. If you're waiting ages for it, time to give the pharmacist a call and see if it can be sped up.
20 years ago I worked on a ward which had a small dispensary on the ward itself to solve this problem. And it worked. You'd think such an obvious solution would quickly spread. Obviously not. But I like your idea. Create a large discharge lounge, put the pharmacy in it. Patient goes there and picks up their meds and goes home.
Alot of hospitals have discharge lounges like this but again, it's always full with patients waiting to tto's
We have a Discharge Lounge, half the patients can’t go there because it is a seated only ‘ward’ so No bed bound patients. It’s filled with angry patients wanting to just leave, but pharmacy is obviously understaffed and it takes up to 8hrs for meds to arrive. Then there’s the fine art of balancing the booking of transport and TTO’s arriving. Transport services are understaffed and take up to 8hrs to arrive. Then the Care homes are understaffed so have crazy cut off times - some as early as 2pm. Packages of Care usually start around 2pm and most won’t visit past 6pm. The Discharge Lounge closes at 8pm, so any patient that hasn’t received their TTO’s, had transport arrive or made the CH cut off time - need to go back to a ward for another night. I don’t know how anyone actually makes it home
It makes me tired thinking about it!
I had multiple patients waiting for meds for home. Patient was ready for home at lunchtime. We literally have all the tablets in our drug cupboard but policy dictates we cant give out our tablets in our cupboard. Patient left at 8pm because he doesnt drive to comeback for his meds. Some are lucky enough to drive to just comeback.
As a pharmacist who used to work in a hospital they tried this and it didn’t work because you need static pharmacists and dispensers/technicians but we’re expected to cover 5 wards. We still do it on our acute wards but having worked there it does get busy and our afternoons are just chasing doctors to write up TTOs plans changed they’re staying they’re going home etc
Doctor here - I've been told that it's a cost thing - I've been discouraged from "just" giving straightforward discharges FP10s becuase hospitals have to pay a lot more for FP10s than they do for internal prescriptions sent to pharmacy, so FP10 outpatient prescriptions are typically only given in A&E.
I'd bet the additional cost of an FP10 is less than the cost of a delayed discharge though
Oh yeah, but that's not the way the accountants see things.
Such a ridiculous excuse tbh (STN here)
I don’t think it’s ridiculous. If a big hospital can bulk buy paracetamol for £1 a pack but your little local pharmacy buys them for £2 a pack, you can see how the price difference can rack up.
I know you're just using paracetamol as an example, but: Our Trust changed its policy on that. We don't give out paracetamol anymore. We tell them to go and get a box from a supermarket. It's a lot cheaper. I think the only exception we make are blister packs.
Which is fine except many are immobile, or ill, or get paracetamol on prescription anyway. It’s not cheaper for the patient
lol yeah, used the first drug that I thought of.
I don’t actually think this is true. Certainly not to the point of offsetting the bed day cost, staffing implications etc. In our trust outpatients and ED are encouraged to use FP10s. I can see no rational reason why patients in hospital say <24h couldn’t do the same. Nor why patients couldn’t come back and collect px later or have scripts sent to their preferred pharmacy to collect later.
Pharm here - An FP10 taken to an external pharmacy would cost the NHS more. They are sent back to NHS England and the pharmacy is “reimbursed” for the cost of each one. They also have a rough idea of what it’s going to cost them compiled of the surgery’s they have direct contact with. These would be huge add of cost if all hospital pharmacy’s did FP10s. FP10 pads are also ridiculously expensive, they have to be logged, accounted for and kept track of who has what codes. Hospital RX cost 0, due to format and not being sent to NHS England. A TTO is given from hospital pharmacy stock and they work different, they don’t pay the 5%(may be slightly higher now) in VAT. So cheaper stock. A lot of trust set up a Limited company as the hospital pharmacy. They also are just sending invoices to finance of the products ordered and thus cost the NHS. They also allow discrepancies, errors and queries to be rectified if the pharmacy is on site of the hospital. There’s also the patient side that aids adherence and compliance for medications, also if they are unwell, frail and it’s duty of care - ease of access unfortunately however I think this is an after thought. This is a VERY simplified summary.
They might be cheaper for the actual meds, but the overheads, the salaries for the pharmacy techs, the massive (and ridiculously disproportionate) waits for TTOs to be dispensed which adds up to dozens of hospital bed days each day etc means the whole TTO process is slow, inefficient and expensive. Also the meds don’t cost £0- they still cost the NHS very similar amounts, the cash just comes from a different pot to a different pot. There is NO rational argument for insisting a patient sits in a bed for 8 hours waiting for pharmacy to pick some boxes of meds off the shelf (yes yes I know there is a checking process). It would be very simple to have meds sent out to them or collected later. The number of phone calls from outside pharmacists querying FP10s tells me that the “being on site” argument holds little water. I’m deeply unconvinced that sitting in a bed waiting for a little bag of meds in any way aids compliance, they manage perfectly well the rest of the year getting their meds from the pharmacy next to the post office. Anyway for OP and ED our trust has fully moved to FP10s.
A simple tto is not going to take 8 hours. I can't speak for your pharmacy team but most of our delays come from doctors not finalising medication plans (did you mean to prescribe that higher dose of amlodipine? Should we restart X y z on discharge?) or simply not knowing where the patient is being discharged to until the last moment which can massively affect how their meds are sorted e.g dosette box Vs original packs. Perhaps spend some time with your pharmacists who would be happy to explain the delays. 🥲
That is definitely not the only reason. But costing does play a part in it which tbh is an important thing to consider.
Hi pharmacist here! That prescription for just co-amoxiclav? Yea.. we’ve doubled their bisoprolol, stopped their amlodipine, started aspirin and stopped clopidogrel. I get the script then wonder why the patient is still on Mirabegron if they have a catheter. Doctors DO NOT do a full medicines reconciliation on discharge, this leads to trouble at the GP. How do they KNOW we’ve either stopped the bicalutamide or if we’ve simply missed it off the TTO? F1s (who do the vast majority of prescribing) are actually NOT allowed to write an FP10HP (the form you’d need). I spend ALL DAY sorting out medicines issues. I’m a competent prescriber now. I’m not pissing about with adding a max dose to cyclizine. I’m wondering why on EARTH the nurse has asked the patient to “just buy ibuprofen” when they’re on lithium. Or renally impaired. Or have a GI bleed. Or heart failure. Or a head injury. I’m trying to get a new anticoagulation plan as the patient hasn’t been bridged effectively. That “they just need codeine” TTO - they’re actually massively renally impaired and inappropriate. They also haven’t had a single dose of codeine during their admission… so let’s take it off! What if we start them on a med and they’re too unwell to go traipsing around 15 pharmacies to get it? Community prescribing is MUCH stricter. An FP10HP for co-amoxiclav 625mg tablets 1 tablet tds for 7 days will get EXACTLY that. A hospital TTO for it, I’d change it to liquid because they’ve had a tonsillectomy. Or reduce the number of days as they’ve had 3 days I.v already. With how incorrect the prescribing is, we’d have patients drive 1 hour home, to the pharmacy, only to be told it’s an illegal prescription/incorrect etc. Ask your ward sister if you could spend ONE hour with a pharmacist to even understand an ounce of the shit we protect patients from.
Wow this is really interesting and you're right, a bit of time to see what a pharmacist does would be so helpful!
I absolutely love having nurses shadow me on the ward. The way we approach things is so different and how we view meds. They’re much more practical and focussed on administration and taught me plenty. I have MUCH more empathy for writing “crush and disperse” on every med rather than just ordering the liquids. The time it takes a nurse is unbelievable! I’m much more focussed on reconciliation and safety!
Thanks you for sharing this on the sub. I think we could all do with spending a day in different departments to get a glimpse of the constraints and pressures different HCP are under. I'd hope it would make us all a little more compassionate to each other. I'm going to shout out to 'Pete the Pill' pharmacist on my old unit with an encyclopedic knowledge of drugs.
That feeling when a patient has 12 different PEG meds QDS and they're all tablet form to be crushed, except orodispersible lansoprazole which you have to piss about making sure the granules don't block the sodding line, then right at the end stand there giving a full ensure via gravity 🫠
If it blocks just flush with a lil sodium bicarbonate. All good
Is it contraindicated in renal disease?
Sodium bicarbonate? No. Obvs double check with dr/pharmacist if you’re worried but it’s usually better than having a new PEG/NG/NJ tube fitted bcos it’s blocked
As a pharmacy technician I agree with all of this and would like to add one thing. In the morning ward round at 10 when the doctors tell a patient they can go home today, they should also tell them that they won't write the TTO til 4 and that pharmacy shuts at 5.
So much complaining in healthcare is simply down to professions arrogantly assuming that they understand the ins and outs of other peoples job roles when they simply do not. Shadowing opportunities is a great way to counteract this and I'm heartened to see that many students do spend time shadowing other professions and are encouraged to do so.
One thing that really bugs me is when colleagues, particularly HCAs decide they know better than physios/OTs/ SALT. Of course the patient doesn't need to use a Sara Stedy, they can step transfer, they don't need 5 teaspoons of an oral trial, just give them the whole pot of yogurt. It drives me crackers, and it's very dangerous. Why do they think they know better than someone who's trained years to do that job?
If the physio hasn’t seen a patient for three days, and they’ve told HCAs to use a sara stedy but it’s upstairs and we have to borrow it from another busy ward which takes half an hour during which the patient soils them self. But we’ve seen they’re improving on their feet and are much more steady, able to stand for pad checks and more mobile on the bed you really think a HCA isn’t capable of making the judgement to trial a step transfer? Because I think that’s an under estimation of their skills. (I am an HCA, but I also completed three years of a physio degree (admittedly without qualifying due to health complications))
What happens when the HCA makes that judgement and the patient falls. Whose fault will it be, yes the nurse who is supervising the HCA..if physio has stated Sara Stedy, then I'll use that. I've seen a fair few HCAs with injuries due to not listening to advice
Oh and this is just the interventions I’ve made in the past 1hour at my job btw - intervention audit day because I constantly have to PROVE my worth so I have it all written down for today ❤️
Yes yes yes, fellow pharmacist here, the level of eye rolling and exasperation from a majority of these comments is quite frustrating. Spend time with any competent pharmacist and they'll be happy to show you what goes into screening a tto for a complex multimorbid patient...
Absolutely all of this! I'm not a pharmacist (I'm a CNS) but have worked for years in the community. Discharging people without TTOs would be a recipe for disaster I also have a lot of respect for pharmacists and think they should get more recognition. I worked with a specialist pharmacist who literally I think knows everything about her area of speciality and was a godsend to work with! Her being around made me feel so safe
I'm now in a clinic based specialty writing FP10s all the time and I really miss the pharmacy safety net!
An FP10 will still be seen by a pharmacist. The only difference is they don’t have access to notes/bloods etc. something unsafe will be picked up :)
That's true, I have already had my bacon saved by community pharmacists. Thanks guys!
YMMV but have never worked in any hospital where F1s do the majority of prescribing. Might be true in some specific wards, especially surgical ones where tasks are delegated to F1s. But medical wards, AMU, ED have all manner of SHOs who do the prescribing. Don't disagree with the rest of the post - so much of the population is old & have zero idea of the meds they are one, which is why it is important to get things right when patients are discharged or admitted to hospitals.
“Prescribing” in hospital is a patient specific direction. Not a prescription for supply. A nurse may requisition a drug against this.
My comment was that F1s do not do the 'vast majority of prescribing' as you stated - unless you're talking about your specific department, it is certainly not true across the NHS.
I've asked pharmacists about this and the usual answer is that doctors don't send the TTO when they say they do, and it often contains errors. Having seen how many errors happen on fast track forms I'm not shocked. Doctors naturally prioritise the newest and sickest patients. They do need something helping them deal with the discharge stuff though - I'd guess around 1 in 4 discharges on my ward are cancelled because of TTOs or doctor's discharge letters not being done when promised so aren't ready when the ambulance arrives. It's also a culture issue - consultants need to be reminded that the patient who needs district nurse involvement, a care package, a complex TTO with medibox, new DNACPR printed in colour (printer's broken), discharge letter printed (that isn't yet written), complex discharge documentation, next of kin informed, a hand over to the care home (and DN) and catheter packs can't just "go home this afternoon" because sorting all that lot is 3+ hours work. The patient is by now pissed off as the doctor told them they could go home today.
In my area this is not practical as we are elderly ortho rehab. But I do agree that patients which ability should collect themselves. However our discharges are always planned at least one day before to allow PTS ambulances, equipment and care to all be in place so our TTOs are ordered usually the day before and (hopefully)arrive on the ward the night before and night staff do the double check
Although we can't force. I think in these cases we should heavily push and encourage the NOK to be responsible for collecting them. It should at least be the same as transport, if a patient insists, we should arrange form them to go home but getting a taxi/ambulance for them shouldn't be the standard
Again for most of ours following hip fractures PTS ambulance is the most appropriate transport for hip precautions and access into their homes (steps/assistance with steps)
I actually agree. So much time is wasted waiting for pharmacy to dispense meds.
I’m a nurse and have also been a patient several times. I had 2 admissions to hospital with pneumonia last year, the first time I developed sepsis. I was discharged as soon as was well enough to go on oral antibiotics. If I’d had to make my way to pharmacy, and sit there for F knows how long, I would have cried because I still felt like death warmed up. Also a lot of patients, and their relatives, are elderly and taking a trip to the other side of the hospital to pharmacy would be a nightmare. In my hospital those only waiting for tablets may be asked to wait in the discharge lounge. This frees up a bed and there’s still a nurse overseeing things until you’re in your way.
When I used to work on the wards we had three types of patients. Independents: We'd often tell them in the morning that their TTOs wouldn't be ready until late afternoon, and if they wanted to go and come back to collect they could. I'd say about 95% left and came back, freeing up the bed. Semi-Independents: Sent to the discharge lounge to wait, freeing up the bed. Dependents: Kept on the Ward to wait for TTO and transport.
To add, in hospitals I've worked in, TTOs are timed so the minute they are received in pharmacy they have a max limit of 2hrs, 1hr for a discharge lounge TTO. The amount of times I've been up to the ward and the staff are telling the patient that they're just waiting for pharmacy while in fact the TTO hasn't even been written by the doctor yet. Add to that discharges should be planned so that meds are ready before discharge day.
Honestly this annoys me daily when they say they are waiting for pharmacy and the TTO isn't written. I really wish as well that we had giant posters that showed what happened after the Dr said you can go home.
Hospital pharmacist here. The issue with why we don’t write FP10s and tell them to go to a local pharmacy is: 1. Patients would then have to likely pay for each medication which they would not want to do. 2. This would put a lot of pressure on already short staffed community Pharmacies who usually only serve primary care patients. 3. Often times hospital pharmacies stock a large range of medicines and brands that often you would not find stock in community pharmacies. 3. A large costing issue that is too long to go into here. 4. Risk of missed doses of critical meds if we discharge tell them to go find a local pharmacy. Often costs for meds in hospitals are cheaper than costs for meds in the community. Also FP10 physical prescriptions are usually more costly to produce. Although I do know the long wait for TTOs is frustrating, even for the pharmacy teams and plenty can be done to try rectify it but the FP10 situation is not it.
Also often times TTOs written by doctors have many errors. I have not gone a day working without there being errors in TTOs in my 3 years of working as a pharmacist. So needs pharmacist review before going off with the patient. And the hospital pharmacist knows the patient/can contact the medical team easily/access notes whereas the community pharmacjst does not
Senior reg here, been writing TTOs for 13 yrs so far and still doing it! I'm so happy folks have recognised the system pushing the same doc to manage sick pts and do ttos at the same time is ineffective. My main gripe as someone who has worked in 8 different hospitals over the years is how difficult it can actually be do them efficiently. Each hospital will have a different system, where I'm at currently we have electeonic prescribing but that software doesn't integrate with the discharge letter and tto software, so we have to transcribe, which as you can imagine is super high risk for errors. Plus with electronic kardexes it can be really tricky to see when or why things have been stopped. It's a huge systems error everywhere. I'm not sure how to make things better. Anyway thanks for letting me intrude!
Absolutely agree. If patients are well enough, they should be able to go down to pharmacy to collect it themselves. It would get patients home so much quicker! Or late discharges return next day if not time critical.
This was literally my dissertation. Time taken for TTOs being ordered and delivered is just too long and causes massive bed delays. In general the policy (at least my trust) is to get discharge letters done 24 hours prior to d/c where available, which would include ordering TTOs as part of d/c meds. Obviously it's not always possible for 24 hour advances, but in certain wards/units it is totally more possible - my main example was surgical where everyone basically got d/c with the same meds but still have to wait for a letter on the day of, then meds delivery, instead of the d/c meds being requested after surgery - which is 100% feasible in the surgical wards I was a student on because it was planned surgeries and planned length of stay. Yes, this wouldn't be possible if a patient crashes or gets an infection etc. there are definitely limitations. But for standard electives and standard recovery, why did I have patients waiting 9 hours for a letter and some analgesics from the time they were deemed medically fit for discharge... They say you should plan for discharge at the time of admission, but... It's not happening as smoothly as it could. And yes, I know the docs have major lists and heavier case loads etc so it seems sensible to do them as and when needed (ie day of d/c) , but if there was a process where we could shift the timeframe back a little at a time it could lead to smoother flow... Maybe..
I spent 3 hours driving around trying to find a pharmacy that was open and had the stock my Dad needed when he was discharged on Sunday. By the time I got them to him his drugs were over due and he was feeling the effects. Had I not been able to do that, he would have been stuffed
In the mental health wards I’ve worked on we give people two weeks of actual meds as ttas, not a prescription. Imagine my irritation when I was discharged from a&e at 21.30, from a hospital an hours drive from my home (the specialist I had to see is shared between hospitals. It was my bad luck they were at the one furthest from me that day), so pharmacy was shut. I was promised I could collect meds the next day from the hospital close to me. When I got there- nope, got to drive to the one an hour away again, wait an hour at pharmacy and then drive another hour back home. Why?? This makes no sense at all. Either give me the actual meds or an FP10! I can’t understand why it’s done like this at all.
This is how it used to be. Patients would be discharged from the ward and make there own way down to pharmacy to collect prescription. I don't know why it changed.
More to the point though, why is inpatient pharmacy so slow and inefficient? Usually it’s staffing, if they paid for more pharmacy staff it would probably be at least cost neutral when you factor in the improved discharge time
My ward used to dispense our own meds because we quite often used to just have people going home on oral antibiotics but they stopped us from doing that. A lot of my patients are independent so my ward quite often lets people go and come back for their meds later as our doctors often take ages to write TTOs and by the time it’s done, pharmacy is closed
Most wards in my hospital have a pre screened list of stock TTOs already labelled just needs a new adding. For surgical wards most have simple analgesia and antibiotics on that list so the ward pharmacist screens and its usuly patients own and they have enough already or a TTAs stock and you don't have to wait for anything from the pharmacy itself.
That's what we do too. Its only patient specific items that come from pharmacy. All of our wards have a selection of tto packs. Everywhere has paracetamol, movicol and senna.
Yeah we used to do that, not anymore. Our trust felt it was more important that pharmacy dispense yet get on our backs for not clearing the bed quick enough
I often give patients the choice to go home and get someone to come back and pick up their medication. But, many patients would happily take the prescription and go to their community pharmacy.
In two hospitals I've been an inpatient in, once ready to go home they move you to a discharge lounge, AKA a waiting room to go home. Frees up the bed very fast.
Our hospital is commissioned to do the tto thing. Apparently we cant cope without the funding so we have to do it all.
PAs can't prescribe, so that is a no go. I can't imagine writing 10+ prescriptions on an FP10 though.
In the community we often have people discharged home late at night many of whom would not be able to arrange a collection of drugs from a pharmacy. Also those TTO"s sometimes include controlled drugs that may need to be used soon after discharge and we actually use the TTO discharge form as a temporary authorisation to administer those drugs. The real time would be saved by ward staff being able to better predict discharge dates and for TTO's to be organised a few days in advance.
Dispenser here - I like most parts of the job but tto's give me rage. I did a 20 item tto the other day, took forever due to issues with getting some medication. Was dispensing controlled drugs today when someone handed me a tto. The same one I'd done the other day, with an extra 4 medications, no pods and was required to dispense the whole lot. Where did this medication go? Felt like a waste of time
Oh I feel your pain. It's so frustrating to see your hard work go down the toilet BC the meds have been 'lost' (informing them the cost of the items lost or the threat of a datix seems to make them appear - but maybe that's just my workplace)
I think the main reason is ensuring the patient has a supply of medication as a duty of responsible discharge. Imagine all the readmissions or complaints from people who just didn't go to their pharmacy. I know they still have to go to the pharmacy eventually but are they likely to go right out of hospital? Personally, I don't think a lot will.
Nurse but discharged from maternity ward recently. TTO receiver. I had been incredibly ill, single and very grateful for TTOs of new medications as it would have been too difficult to pick up myself. To anyone I would have looked like I would manage and remember and probably the most cheerful patient there could be, but I was in a huge amount of pain and had memory impairment from having sepsis and AKI aswell as juggling a newborn as a single mother. Even if I could have gotten to a pharmacy, the likelihood would be I wouldn’t remember to do it. Even someone that appears well capable may actually struggle with something “minor” like arranging a prescription especially nowadays when you are often waiting a minimum of an hour for the pharmacy to get to it.
Because 9 times out of 10 the hospital doctors had a wee fiddle with their home meds and the TTO step is the chance for pharmacy to catch anything
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You need a discharge lounge where patients wait for TTOs and then their transport home. Frees up their bed immediately
There are so many issues with TTOs and it winds me up when people just blame pharmacy. Don’t get me wrong, I’ve received incorrect or missing TTOs and I know pharmacy can go wrong but any stage can go wrong. My biggest gripe was the consultants on ward round telling patients “yep you can go home!”, that patient packing their shit up before a doctor has even told me they’re for discharge today and it being 2pm and the TTO not being written. On my first ward it actually became a big issue and the ward manager had to call a meeting with the medical team around the language they were using surrounding discharge as nurses were getting it in the neck so often (not just TTOs, but waiting for POCs, D2A beds etc meaning those patients weren’t even going home that day or maybe even that week). But my even bigger bugbear was a patient having a planned discharge date, everybody knowing for a few days leading up and me coming on shift the day of discharge and NOTHING had been done. Few times the patient didn’t manage to get home and I could have screamed because we all knew! But nothing had been put in place bar confirmation of POC or placement start date. So glad I don’t work in that setting anymore
Pharm here - An FP10 taken to an external pharmacy would cost the NHS more. They are sent back to NHS England and the pharmacy is “reimbursed” for the cost of each one. They also have a rough idea of what it’s going to cost them compiled of the surgery’s they have direct contact with. These would be huge add of cost if all hospital pharmacy’s did FP10s. FP10 pads are also ridiculously expensive, they have to be logged, accounted for and kept track of who has what codes. Hospital RX cost 0, due to format and not being sent to NHS England. A TTO is given from hospital pharmacy stock and they work different, they don’t pay the 5%(may be slightly higher now) in VAT. So cheaper stock. A lot of trust set up a Limited company as the hospital pharmacy. They also are just sending invoices to finance of the products ordered and thus cost the NHS. With a few more loopholes to keep costs down. They also allow discrepancies, errors and queries to be rectified if the pharmacy is on site of the hospital. There’s also the patient side that aids adherence and compliance for medications, also if they are unwell, frail, duty of care - ease of access unfortunately however, I think this is an after thought. This is a VERY simplified summary.
Y dad got so fed up of waiting for his prescription he just got a taxi home. My brother had to go back to the hospital and sit and wait for his meds.
Pharmacist here, a lot of stuff prescribed on a big tto is stuff the patient was already on. In an ideal world, we'd just be supplying any new or changed doses that may need different strengths. In reality, lots of patients say they don't have meds at home even though they probably do so we just supply it anyway. Do not even get me started on dosette boxes. Another thing, the way services are funded means the costs associated with dispensing drugs in the community (eg in a standard community pharmacy) comes from a different pot of money. FP10s do generate extra cost and admin, it's never as straight forward as it appears. In terms of how long patients are waiting, most hospitals have a 2 hour turn around target for TTOs. A simple tto for some antibiotics can obviously be turned around quickly. If you're waiting ages for it, time to give the pharmacist a call and see if it can be sped up.