Professional standards for hospital pharmacy services: handbook

Professional standards for hospital pharmacy services: handbook

The standards handbook is an overview of the legislation, regulation and other key resources that underpin the whole Standards document.

Published: 14 August 2026

This was published when the organisation was the Royal Pharmaceutical Society.

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Professional standards for hospital pharmacy services: background

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This was published when the organisation was the Royal Pharmaceutical Society. Report Seven day services in hospital pharmacy: Giving patients the care they deserve, provides a summary of the meeting between the Society and colleagues to discuss the challenges faced in moving to seven day services and outlines emerging themes for the pharmacy profession to consider when developing seven day services supplemented by actions for consideration. On the 20 May 2014, members of the Royal Pharmaceutical Society (now the Royal College of Pharmacy), along with other colleagues from across Great Britain, gathered in London to discuss the challenges in moving to seven day services so that pharmacists can better care for patients. This is a report of that meeting. It opened with a discussion on the wider context in which seven day services are developing, as illustrated by the RCP’s Future Hospital Commission and NHS England’s Seven Days a Week Forum workstreams, and then highlighted case studies on diverse approaches to extended and seven day pharmacy services. Download the seven day report (PDF) Related resource: https://www.rcpharm.org/professional-standards/professional-standards-for-hospital-pharmacy-services/

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Introduction

The standards handbook is a supporting resource which has been updated and published alongside the RCPharm Professional standards for hospital pharmacy services. It provides useful information and links to legislation and resources relevant to the standards. We recommend that the handbook is used in conjunction with the standards to provide readers with the detail that supports them.

The standards handbook is published electronically on the RCPharm website. It is an evolving document, developed by your feedback, and as such is not intended to be a comprehensive bibliography.

An overview of core legislation, regulation and other key resources is given first. These underpin the whole standards document. Following this, a list of references and resources is given for each standard.

Proviso

  • We have tried to list key, generic regulatory requirements that are relevant to the standards; however, these may not be applicable to all types of care settings.
  • It is helpful to bear in mind that the Professional standards for hospital pharmacy services are an overarching document, of which some standards and descriptors are based on good/advanced practice, and therefore supporting/relevant regulation may not exist in every case.

We welcome any additions/amendments to this list. Please email: [email protected]

Core legislation

The list below indicates the key legislation around handling medicines by hospital pharmacy services:
General

NHS legislation:

  • Health and Care Act 2022 – establishes Integrated Care Systems in England on a statutory footing and reinforces the ambitions of the NHS Long Term Plan.
  • Health and Social Care Act (Northern Ireland) 2022 – dissolves Regional Health and Social Care Boards and migrates their functions to the Department of Health.
  • The Health and Social Care Act 2012 – established NHS England and promoted the involvement of patients and their carers in decisions about the provision of the health service.
  • Health Act 2006 – devolved statutory powers to the home nations.
  • National Health Service Act 1946 – created the National Health Service in England and Wales.
  • National Health Service (Scotland) Act 1947 – created the National Health Service in Scotland.
Regulatory legislation:

Medicines and medical device legislation:

The EU Medical Devices Regulation (2017/745) and in vitro Diagnostic Medical Device Regulation (2017/746) apply in Northern Ireland

*Came into force on 1 December 2022.

Controlled Drugs

Health and safety legislation

Confidentiality and data protection

Regulation of individuals

There are a number of key aspects of regulation relevant to the delivery of hospital pharmacy services. The following sections refer to generic resources and legislation only, and do not aim to cover the more specific requirements for services such as manufacturing, mental health legislation etc.

General Pharmaceutical Council (GPhC)

The General Pharmaceutical Council (GPhC) is the independent regulator for pharmacists, pharmacy technicians and pharmacy premises in Great Britain. All registered pharmacists and pharmacy technicians are required to comply with their Standards for pharmacy professionals (May 2017), in the course of their professional duties. 

The GPhC states that as a pharmacy professional, you must:

  1. Provide person-centred care.
  2. Work in partnership with others.
  3. Communicate effectively.
  4. Maintain, develop and use your professional knowledge and skills.
  5. Use professional judgement.
  6. Behave in a professional manner.
  7. Respect and maintain the person’s confidentiality and privacy.
  8. Speak up when you have concerns or when things go wrong.
  9. Demonstrate leadership.

Pharmacy professionals are accountable for their practice and must use their professional judgement when deciding on a course of action. 

Chief pharmacists (or equivalent) also have specific responsibilities in relation to delivering the pharmacy service and should take into account:

In September 2012, the GPhC published new standards for registered pharmacies. The Standards apply to all pharmacies registered with the GPhC. The GPhC has also provided additional information regarding which service models, including those that involve hospital pharmacies, require registration.

Pharmaceutical Society Northern Ireland

The Pharmaceutical Society Northern Ireland (PSNI) is the independent regulator for pharmacists, pharmacy technicians and pharmacy premises in Northern Ireland. 

As a professional requirement of registration, all pharmacists in Northern Ireland are expected to abide by the Pharmaceutical Society NI Code (Professional standards of conduct, ethics and performance for pharmacists in Northern Ireland). 

The Code details five mandatory principles that explain the required standards of professional behaviour. 

These are:

  • Principle 1: Always put the patient first.
  • Principle 2: Provide a safe and quality service.
  • Principle 3: Act with professionalism and integrity at all times.
  • Principle 4: Communicate effectively and work properly with colleagues.
  • Principle 5: Maintain and develop your knowledge, skills and competence.

Additionally, the following documentation should be taken into account:

Regulation of organisations

Regulatory standards that apply to hospitals are set by systems regulators across the United Kingdom. These regulate NHS and/or private providers, as well as social care providers. 

The main regulators in each country are:

Care Quality Commission (CQC)

The CQC regulates both the NHS and independent providers of health and social care in England, to ensure they comply with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the CQC (Registration) Regulations 2009.

The CQC replaced their outcomes framework and introduced a new inspection framework in 2015. Pharmacy services are expected to comply with CQC “Fundamental standards”, which replaced the previous “Essential standards”. 

CQC inspections are based on an assessment tool using Key Lines of Enquiry (KLOE) with a set of questions on five key components:

  • Safety
  • Effectiveness
  • Caring
  • Responsiveness
  • Leadership

The CQC has provider handbooks on their approach to regulation for each of the sectors they regulate, including acute hospitals, ambulance trusts, community health services, mental health services and the independent sector.

NHS England publishes a single oversight framework which covers five national themes. This framework has been designed to help NHS providers ensure alignment of priorities across the NHS and with wider system providers. 

They are linked to CQC’s questions but are not identical:

  • Quality of care, access and outcomes.
  • Preventing ill-health and reducing inequalities.
  • Finance and use of resources.
  • People.
  • Leadership and capability.
Healthcare Inspectorate Wales (HIW)

HIW regulate both the NHS and independent providers of health care in Wales. The Health and Social Care (Community Health and Standards) Act 2003 (Part II, Chapter 4) gives HIW the power to carry out inspections, reviews and investigations of the NHS, or services provided for the NHS. While the Care Standards Act 2000 gives them the powers and responsibilities, on behalf of Welsh Ministers, for the registration and inspection of independent healthcare services in Wales.

HIW replaced their health standards framework in 2015. Pharmacy services in the NHS are expected to comply with the Welsh Government Health and Care Standards. We have guidance on how HIW inspect NHS providers.

Independent healthcare providers are expected to comply with the standards as defined by the Care Standards Act 2000 (section two) and the National Minimum Standards for Independent Healthcare Services in Wales (April 2011), the Care Standards Act 2000 and the Independent Health Care (Wales) Regulations 2011. You can also find guidance on how HIW inspects independent providers.

Healthcare Improvement Scotland (HIS)

HIS regulates organisations in NHS Scotland and independent healthcare providers in Scotland, to ensure that they comply with standards and regulations. They were established as a health body by the Public Service Reform Scotland Act 2010 and the Public Bodies (Joint Working) Act 2014.

They inspect NHS services in acute hospitals against the Health and Social Care Standards (2017), HAI Standards (2015), the HIS Quality of Care Framework (2018) and any other standards that become relevant during the course of the inspection. Independent providers are also inspected against the HIS Quality of Care Framework (2018). Findings are reported under the Framework domains and quality indicators.

Regulation and Quality Improvement Authority (RQIA)

The RQIA is the independent body responsible for monitoring and inspecting the availability and quality of health and social care services in Northern Ireland and encouraging improvements in the quality of those services. The legislation under which RQIA was established is The Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003.

The Quality Standards for Health and Social Care set out the standards that people can expect from Health and Personal Social Services (HPSS). You can also find guidance for different types of service providers.

Indemnity

NHS Resolution

In April 2017, the NHS Litigation Authority brought together its three main functions under the umbrella name, NHS Resolution.

NHS Resolution is an arm’s length body of the Department of Health and Social Care that provides expertise to the NHS on resolving concerns and disputes fairly, sharing learning for improvement and preserving resources for patient care. 

The main functions are:

They provide indemnity through the Clinical Negligence Scheme for Trusts (CNST). In 2022, they published a new strategy for 2022 to 2025, which focuses on early intervention and avoiding unnecessary court action and other formal processes.

Organisations in England will find the Standards can help to support maintaining high professional standards.

Clinical Negligence and Other Risks Scheme (CNORIS)

CNORIS is the indemnity provider for NHS Scotland, run by a private provider. Its primary objective is to provide cost-effective risk pooling and claims management arrangements for Scotland’s NHS Boards and Special Health Boards.

Hospitals in Scotland may find the Standards can help meet CNORIS risk requirements.

Welsh Risk Pool Services (WRP)

WRP is a support function for all health bodies in Wales and is part of the NHS Shared Service Partnership Legal and Risk service, providing indemnity for Trusts and Health Boards. Their emphasis is on improvement to patient safety and outcomes. The risk pooling scheme covers all risks relating to NHS activity.

Hospitals in Wales may find the Standards can help meet WRP risk requirements.

Northern Ireland

Each health and social care trust provides its own indemnity, which is funded by the Department of Health, Social Security and Public Safety.

Other useful resources relevant to the standards

Key reports

These key reports support across all the domains, standards, descriptors and supporting statements:

International standards

European Association of Hospital Pharmacists

The European Statements of Hospital Pharmacy express commonly agreed objectives which every European health system should aim for in the delivery of hospital pharmacy services. A self-assessment tool and evidence map have been developed to support implementation of the statements.

The Common Training Framework for the hospital pharmacy profession support the raising of standards in hospital pharmacy practice and thereby enhances the quality of, safety of, and equity of access to patient care in every European country.

International Pharmacy Federation (FIP)

In 2015, FIP approved revisions to the Basel Statements: The future of hospital pharmacy practice. These list 65 statements which cover global standards of practice for hospital pharmacists. In addition, a self-assessment tool has been developed so that hospitals can measure how they align with the Statements and identify areas to focus efforts on improving alignment.

American Society of Health-System Pharmacists (ASHP)

ASHP have produced an international accreditation of hospital and health system pharmacy services. They have also developed a Practice Advancement Initiative 2030, which includes tools and resources aimed at advancing practice.

Society of Hospital Pharmacists of Australia (SHPA)

The SHPA have produced standards of practice for clinical pharmacy services. These aim to describe the activities delivered by pharmacists for patients to minimise the risks associated with the use of medicines and to optimise the use of medicines.

Hospital pharmacy benchmarking metrics

RCPharm, through its Hospital Expert Advisory Group (HEAG), has developed a consensus on definitions for benchmarking metrics relevant to acute hospitals. The aim is to provide a consistent basis for the collection of data, which will allow acute hospitals to benchmark performance against each other most effectively.

The NHS Benchmarking Network supports members to improve the quality of health and social care services through a benchmarking service. Pharmacy and Medicines Optimisation is a core project in the Acute sector theme. It aims to support medicines management teams by providing comparable data that can be used to inform decision-making and provide evidence-based examples of effective medicines optimisation.

NHS Model Health System (England only): The Model Health System is a data-driven improvement tool that enables NHS health systems and trusts to benchmark quality and productivity. It is an easy-to-navigate tool that can be used by all NHS staff. The user can explore and compare productivity, quality and responsiveness data to identify opportunities to improve.

Got a useful resource that is not listed here? Let us know by emailing: [email protected]

Domain one: The person’s experience

Standard one: Putting people first
Standard outcome:

The principle of ‘no decision about me, without me’ underpins the design and delivery of pharmacy services, ensuring that people using services can make shared decisions about their treatment and medicines. Appropriate support is provided to people to ensure effective medicines use.

Useful resources:

Standard two: Episode of care
Standard outcome:

People’s medicines are reviewed for accurate medication history, experiences of their medication and clinical appropriateness.

Useful resources:

Standard three: Integrated transfer of care
Standard outcome:

As part of the local health and social care system, the pharmacy team ensure safe and timely transfer of information about the person and their medicines between care settings.

Useful resources:

Domain two: Medicines assurance

Standard four: Medicines governance
Standard outcome:

Pharmacy expertise is consistently available whenever people need the service to lead the safe and effective use of medicines. The pharmacy team leads a multidisciplinary approach to safe medication practices across the organisation and within systems.

Useful resources:

Standard five: Efficient supply of medicines
Standard outcome:

Medicines are available, or can be readily made available, to meet people’s needs whenever there is a requirement for them.

Domain three: Delivery of the service

Standard six: Leadership
Standard outcome:

Pharmacy has a clear strategic vision, effective organisational processes, governance and controls necessary to ensure people using services are safe and get the best from their medicines. This is underpinned by strong personal, professional and clinical leadership.

Useful resources:

Standard seven: Systems of work
Standard outcome:

Systems of work are in place and maintained, which support the maintenance of good practice, learning from mistakes, and improvement of services whilst having clear business and financial arrangements.

Useful resources:

Standard eight: Workforce
Standard outcome:

The pharmacy team has the right skill mix, capability, and capacity to provide safe, quality services to people whilst being supported to maintain their personal development and health and wellbeing.

Useful resources:

Professional standards for hospital pharmacy

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Hospital standards supporting resources

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Hospital standards background

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