COVID-19: Guidelines for pharmacists in South Africa

Since the outbreak of COVID-19, and its declaration as a pandemic by the World Health Organization (WHO), the reliance on pharmacists as one of the first points of contact within the healthcare system has been highlighted. This evidence-based review is aimed at providing guidance for pharmacists in community, hospital and other settings in South Africa, on the management of patients with suspected or confirmed coronavirus disease 2019, or COVID-19. The situation is rapidly evolving, and new evidence continues to emerge on a daily basis. This guidance document takes into account and includes newly available evidence and recommendations, particularly around the following aspects relating to COVID-19: • Epidemiology • The virus, its modes of transmission and incubation period • Symptom identification, including the differentiation between influenza, allergic rhinitis, sinusitis and COVID-19 • Social media myths and misinformation • Treatment guidelines and medicines that may need to be kept in stock • Treatment and prevention options, including an update on vaccine development • The case for and against the use of NSAIDs, ACE-inhibitors and angiotensin receptor blockers (ARBs) in patients with COVID-19 • Interventions and patient counselling by the pharmacist. It is critical, though, that pharmacists access the most recent and authoritative information to guide their practice. Key websites that can be relied upon are: • World Health Organization (WHO): https://www.who.int/emergencies/diseases/novelcoronavirus-2019 • National Institute for Communicable Diseases (NICD): https://www.nicd.ac.za/diseasesa-z-index/covid-19/ • National Department of Health (NDoH): http://www.health.gov.za/index.php/ outbreaks/145-corona-virus-outbreak/465-corona-virus-outbreak; https://sacoronavirus. co.za/

Community pharmacists' knowledge, attitude and practices towards the use of complementary and alternative medicines in Durban, South Africa

Background: Atopic eczema (AE) is a common skin disease with an increasing worldwide prevalence, which has almost doubled over the last decade in South Africa. Many patients commonly explore complementary and alternative medicines (CAM) for AE and often initially seek advice from their local pharmacists.Aim: To explore the knowledge, attitude and practices amongst community pharmacists regarding CAM.Setting: The study was conducted amongst pharmacists working in community pharmacies in Durban, South Africa.Methods: During 2016, a cross-sectional study was conducted amongst 158 randomly selected pharmacists, of which 82 responded. Respondents were sent an email with a link to the questionnaire. Where logistically possible, questionnaires were hand-delivered.Results: The majority of respondents were male (n = 46; 56%), aged between 31 and 40 years. Despite most pharmacists not being familiar with various CAMs for AE, many (43%) recommend them, and 50% were amenable to referring patients to CAM practitioners. Despite 51% reporting that patients do ask about CAM for AE, 54% are not confident discussing or initiating discussions with patients. More than half of the pharmacists (55%) had no CAM training but believed it is essential for inclusion in the undergraduate pharmacy curriculum. Most were interested in broadening their knowledge on CAM and felt it would better prepare them in counselling their patients.Conclusions: The study demonstrated poor knowledge and communication about CAM for AE between pharmacists and patients, although pharmacists exhibited strong interests in learning more about CAM. There is a continuing need for education programmes and inclusion into undergraduate curricula that would assist pharmacists to advise patients on different types of CAMs

Community pharmacists' knowledge, attitude and practices towards the use of complementary and alternative medicines in Durban, South Africa

Background: Atopic eczema (AE) is a common skin disease with an increasing worldwide prevalence, which has almost doubled over the last decade in South Africa. Many patients commonly explore complementary and alternative medicines (CAM) for AE and often initially seek advice from their local pharmacists. Aim: To explore the knowledge, attitude and practices amongst community pharmacists regarding CAM. Setting: The study was conducted amongst pharmacists working in community pharmacies in Durban, South Africa. Methods: During 2016, a cross-sectional study was conducted amongst 158 randomly selected pharmacists, of which 82 responded. Respondents were sent an email with a link to the questionnaire. Where logistically possible, questionnaires were hand-delivered. Results: The majority of respondents were male (n= 46; 56%), aged between 31 and 40 years. Despite most pharmacists not being familiar with various CAMs for AE, many (43%) recommend them, and 50% were amenable to referring patients to CAM practitioners. Despite 51% reporting that patients do ask about CAM for AE, 54% are not confident discussing or initiating discussions with patients. More than half of the pharmacists (55%) had no CAM training but believed it is essential for inclusion in the undergraduate pharmacy curriculum. Most were interested in broadening their knowledge on CAM and felt it would better prepare them in counselling their patients. Conclusions: The study demonstrated poor knowledge and communication about CAM for AE between pharmacists and patients, although pharmacists exhibited strong interests in learning more about CAM. There is a continuing need for education programmes and inclusion into undergraduate curricula that would assist pharmacists to advise patients on different types of CAMs

Reasons why insured consumers co-pay for medicines at retail pharmacies in Pretoria, South Africa

Background: Costly prescription medicines with existing cheaper alternatives tend to be purchased by medically insured consumers of healthcare. In South Africa medical scheme members pay higher out-of-pocket payments for medicines than those without insurance. Aim: This study explored reasons for co-payments among insured Pretoria medical scheme members purchasing prescription medicines at private retail pharmacies, despite being insured and protected against such payments. Setting: The study took place in retail pharmacies in Pretoria, Gauteng Province, South Africa. Methods: An exploratory qualitative study was performed. Semi-structured interviews were conducted among purposefully sampled medical scheme members (12) and nine key informants (six pharmacists and three regulators ­ one for the pharmaceutical industry, one for medical schemes and one for pharmacists). Three pharmacies (two corporate and one independent) each were identified from high and low socio-economic areas. Scheme members were interviewed immediately after having made a co-payment (eight) or no co-payment (four) from the selected pharmacies. Interviews were recorded, coded and organised into themes. Results: Co-payments were deemed confusing, unpredictable and inconsistent between and within pharmacies. Members blamed schemes for causing co-payments. Six sampled pharmacies rarely stocked the lowest-priced medicines; instead, they dispensed medicines from manufacturers with whom they had a relationship. Corporate pharmacies were favoured compared to independents and brand loyalty superseded cost considerations. Medical scheme members did not understand how medical schemes' function. Conclusion: Unavailability of lowest-priced medicines at pharmacies contributes to co-payments. Consumer education about generics and expedited implementation of National Health Insurance could significantly reduce co-payments

Nicotine dependence and role of pharmacist in nicotine addiction control

There are about one billion smokers in the world and death toll due to smoking is almost six million people a year. The tobacco use is increasing specially in the third world countries. By 2020, death will increase to more than 70% of smokers in some developing countries. Continuous tobacco use can cause tolerance and dependence. Tobacco dependence is the main cause of morbidity and mortality among smokers. Nicotine dependence is assumed to be present if tolerance, withdrawal and compulsive desire to consume tobacco are existing. It is well documented that environmental and genetic factors influence the possibility of nicotine addiction. Thus, actions are needed at different levels to avoid the health hazards induced by tobacco smoking. Governments have to play a vital role in smoking control. People at large needs to be involved in the fight against smoking. Within the health-sector, health professionals as physicians and pharmacists have a leading role to play because of their knowledge about the dangerous of smoking and its treatment in general. Community pharmacist is one of the most accessible health care professional to the public and can fulfil fundamental role in public health as key providers of tobacco cessation and prevention services. In addition, pharmacists have a significant knowledge of nicotine withdrawal symptoms, drugs used in smoking cessation and with special training can be involved in the treatment programs. Moreover, media campaigns (pharmacy and non-pharmacy groups) are needed to encourage smoking cessation and discourage smoking initiation. However, with any tobacco-use prevention program, it should always be remembered that long time is needed before success becomes effective and apparent

Knowledge, Perception and Practice of Medication Use Review among Community Pharmacists in Southwestern Nigeria

Background: Medication use review (MUR) is an emerging concept in medicine management that has recorded success in many developed countries.Purpose: To evaluate knowledge, perception and practice of MUR among community pharmacists (CP) in southwestern Nigeria.Method: A cross-sectional study was carried out among 100 CP recruited from Oyo and Osun states between January and March, 2015, using a pre-tested questionnaire. Demographic information and CP's knowledge, perception and current practice of MUR were evaluated using open-ended, closed-ended and Likert-scale questions. Respondents' scores for 6-item knowledge test questions and description of specific component of MUR services were categorised as score>3 (good knowledge) and score≤3 (poor knowledge). Descriptive statistics were used to summarize data. Ranked variables were evaluated using Kruskal-Wallis test at p<0.05.Results: Fifty-nine (59.0%) CP from Oyo and 41(41.0%) from Osun state participated. Sixty-five (70.7%) had score>3 indicating "good" knowledge of MUR, while 27 (29.3%) had score≤3 suggesting "poor" knowledge. Forty-two (42.0%) claimed to provide MUR service; of this, 14 (33.3%) had scores>3 indicating those who gave correct description of specific component of MUR. Lack of adequate time for counselling (49; 49.5%) and lack of specialized training for pharmacists (45;45.5%) were cited as barriers to MUR practice. Majority (51; 51.5%) agreed that MUR service should be incorporated into community pharmacy practice.Conclusion: Knowledge of MUR concept among community pharmacists in Oyo and Osun states is considerable, but description of specific component of MUR services by respondents was poor. There is therefore a need for continuous training on emerging concepts among pharmacists, so as to stimulate interest in patient-oriented service

Assessment of continuing professional development activities among pharmacists in Nigeria

Background: Continuing Professional Development (CPD) was developed as formal lifelong learning systems with the aim of updating the knowledge and skills of professionals to meet continual challenge of maintaining competency in practice as professionals. No pharmacy school program can provide all the knowledge, skills and abilities that will be required during one's career as a pharmacist, therefore, the need for pharmacists to engage in CPD.Objectives: The main objectives of this study were to document the CPD activities that pharmacists engage in, find out the reasons for engaging in such activities and determine their satisfaction or otherwise with the activities.Methods: The research was conducted using pre-tested, semi-structured questionnaire, self-administered to pharmacists who have participated in at least one module of the PCN-MCPD program. Descriptive analysis was carried out using the Statistical Package for Social Sciences (SPSS).Results: The results showed that 63.4% of respondents participated in other CPD activities apart from the PCN-MCPD program. Sixty-four percent attend PSN Conferences, 43% attend workplace organized trainings while 41% attend both the PSN Technical Group Conferences and Healthcare related trainings. Furthermore, 69% of the respondents were satisfied with their CPD activities while 35.4% were satisfied with the PCNMCPD program.Conclusion: Pharmacists participate in CPD activities. However, they are more satisfied with the other CPD activities that they engage in than the PCN-MCPD programme. The PCN-MCPD programme should be restructured to recognize the other CPD activities that pharmacists engage in

Assessment of pharmacist's knowledge on use of non-steroidal anti-inflammatory drugs in hypertensive patients with co-morbid arthritis and pharmaceutical services rendered in Ibadan, Nigeria

Background: hypertension and arthritis are two co-morbid diseases that require pharmaceutical care (PC) services. Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used for treatment of arthritis.Objectives: The study evaluated the knowledge of pharmacist on the use of NSAIDs in this set of patients and the PC services rendered to them. Methods: structured tested questionnaires were distributed to pharmacists working in public hospitals and community pharmacies in Ibadan metropolis. The questionnaire elicited information on the demographics of respondents, identification of drug related problems and ways of resolving them, knowledge on pharmacotherapy of arthritis and hypertension. Data was analysed with descriptive analysis using statistical package for the social sciences (SPSS) version 16 for windows.Results: a total of 165 questionnaires were distributed with 124 properly filled and returned giving a response rate of 75.2%. Majority (64.5%) were females, the mean year of graduation of the respondents was 9.12years and 50.8% practice as Community pharmacists. Common PC activities include; counseling (84.4%), monitoring of patients B.P (53.3%), blood glucose measurement (53.3%), monitoring patient's using available laboratory results (44.3%). Majority (85.5%) resolved side effects complaint from patients by reassuring the patients that side effect will subside as therapy continues while 77.4% took full medication history and 65.3% consulted physician for a change of medication. Majority (88.7%) agreed that they encountered prescriptions containing NSAIDs for arthritis in their practice. Good numbers of the respondents had no idea of what measure to take when a patient diagnosed of arthritis and hypertension was prescribed NSAIDs if the blood pressure was control or when it was uncontrolled. Few 16.9% and 8.9% indicated they monitored B.P of such patients with controlled or uncontrolled B.P, while more than half (55.6%) of the respondent indicated that COX2 inhibitor are safer in hypertension as compared to COX1 and that NSAIDs effects on hypertension is dose dependent. Most(77.4%) of them indicated that NASIDs can exacerbate hypertension while 55.6% indicated that NSAIDs can induce hypertension. Conclusion: Respondents' knowledge of the pharmacotherapy with antihypertensives and NSAIDs use in patients with hypertension co-morbid arthritis need to be improved. Good and well established pharmacist physician relationship, refresher courses and remuneration of pharmacist for the PC services will also improve services provided by the pharmacist

Comparative drug therapy problems and pharmacists' intervention in selected health facilities in Ogun State

Background - Regular medication reviews will reduce the occurrence of Drug Therapy Problems (DTPs). This study set out to identify, document DTPs and evaluate the impact of pharmacists´ interventions in selected health facilities. Methods - The study was carried out simultaneously at two tertiary and two secondary hospitals in Ogun States. Pharmacists were trained to document all identified DTPs in prescriptions and impacts of pharmacists' interventions for six months using the documentation form, PCNE V5.01. Data was analyzed and presented as frequencies with test of significance of main parameters. Results ­ One hundred and four (104) DTPs were reported in all the health facilities but with no significant difference in occurrence at the two hospital levels. Commonly occurring DTPs were drug choice problems (35.6%), dosing problems (33.9%), adverse drug reaction (22.8%), drug use problems (4.23%) and drug interactions (1.69%). Most proposed interventions (77.0%) were approved by prescribers with (77.2%) resolution of DTPs in tertiary hospitals. Conclusion- There was no significant difference in occurrence of DTPs in the hospitals but there was higher incidence of non-allergic ADR, contraindication, duration of drug use and duplication of drugs at the secondary level. Acceptance rate of proposed interventions by physicians was high (77.2%) confirming that pharmacists' intervention in rational pharmacotherapy is valuable

Pharmacist Prescribing in the United Kingdom and the Implication for the Nigerian Context

Background: Non-medical professionals including pharmacists have been granted the right to prescribe medicines in the United Kingdom. In Nigeria; only medical doctors; dentists and some nurses in primary care facilities have the legal right to prescribe medicines and patients' access to prescriptions can be seriously affected by a shortage of prescribers and long waiting times in hospitals.Objective: This article presents a review of pharmacist prescribing in the UK including its model; impact; facilitators and barriers and discusses the implications for the Nigeriancontext. Methods: A literature search was conducted in Medline; Embase; International Pharmaceutical Abstracts and Cumulative Index to Nursing and Allied Health Literature databases for studies investigating pharmacist prescribing in the UK between 1990 and August 2013.Results: The review identified that legislative change in the UK has enabled pharmacists to prescribe first as supplementary prescribers then as independent prescribers. This policy change was driven by the desire to increase patients' access to medicines and promote the utilisation of the skills of non-medical professionals while maintaining patient safety. Although more robust research evidence is needed to demonstrate the effectiveness of pharmacist prescribing; available evidence shows that it has had an impact on patient access to medicines.Conclusion: Pharmacist prescribing has the potential to promote access to prescription medicines; free doctors' time to enable them deal with complex cases and promote efficient use of pharmacists' clinical skills in Nigeria as it does in the UK. Factors which can promote the extension of prescribing rights to pharmacists in Nigeria include the current level of pharmacists' training and the clinical roles of pharmacists in some tertiary hospitals

Measles Case-based Surveillance and Outbreak Response in Nigeria; An Update for Clinicians and Public Health Professionals

The Federal Ministry of Health recommendations for response during measles epidemics in Nigeria previously focused on case management using antibiotics and Vitamin. A supplements and did not include outbreak response immunization (ORI) campaigns. However; with the revision of the existing national technical guideline on measles case based surveillance and outbreak response in Nigeria in 2012 in line with the World Health Organization recommendation on response to measles outbreak in measles mortality reduction settings; there is a need to update members of the Nigerian public health community on these revisions to ensure appropriate implementation and compliance. This article therefore seeks to provide clinicians and other public health professionals in Nigeria with updates on recent developments in measles case-based surveillance and outbreak response in Nigeria

Assessment of Community Pharmacists' Willingness to become Tuberculosis DOTS Services Providers in Lagos State

"Background: Hospital based Directly Observed Therapy Short course (DOTS) for the treatment of tuberculosis though effective has constraints to its effectiveness e.g. restricted timings of TB clinics; long distance to travel by tuberculosis patients to TB DOTS clinics; etc. Community pharmacy based TB DOTS services under thesupervision of community pharmacists can address these constraints. Objectives: To assess community pharmacists' willingness to become Tuberculosis Directly Observed TherapyShort course (TB DOTS) service providers in Lagos state; Nigeria. Methods: A 25 item self completion questionnaire was administered to 120 community pharmacists spreadacross three; Association of Community Pharmacists zones of Ikotun; Iyana-Ipaja; as well as Festac zones in Lagos state; Nigeria respectively. These community pharmacists' zones were formed in Lagos state to ensure theease of administration and prevention of the operation of illegal premises in Lagos state and the twelve zones inLagos state are duly recognized by both the Pharmaceutical Society of Nigeria and the State Chapter of the Association of Community Pharmacists. Data was collected on a scale that ranged from 8 to 40 with an assumedneutral point of 24 and statistically analysed. Results: Community pharmacists in Lagos state Nigeria were willing to be TB DOTS services providers as shownby a mean score of 30.53+ 6.71 in 77 of the respondents. On the 5-point rating scale; ""5"" represented thehighest mean score while ""1"" represented the lowest mean score. On the 8 item scale; the lowest mean score is 8and the highest mean score is 40 with a neutral point of 24. The percentage performance was the number of respondents that scored above the critical or neutral point on the rating scale. Statistically not significant association was observed between having heard of TB DOTS services and their willingness (X2 =0.66; P=0.3485;P0.05). Association between training in the provision of TB DOTS services and the willingness observed was2statistically also not significant (X =2.08; P=0.2525; P0.05).So also for the association between number of yearsof community pharmacy practice and their willingness to be TB DOTS service providers (X2=1.18; p=0.371;P0.05). Conclusion: Community pharmacists in Lagos state Nigeria are willing to be TB DOTS services providers. Howevertheir willingness to be TB DOTS services providers is not associated with the level of training that they have hadon TB DOTS services provisions; neither is it associated with their level of awareness about TB DOTS services.Their years of community pharmacy practice experience also had no influence on their willingness to be TB DOTSservices providers."

Willingness to Practice Basic First Aid Care among Community Pharmacists in Lagos Nigeria

Background: The growing incidence of terrorism and/or disasters across the world makes it important that all healthcare professionals get empowered with the skills to offer first aid to selfor others when the need arises. Objectives: The objectives of this study were to assess the knowledge and willingness to practice basic life saving first aid care (FAC) among community pharmacists in a metropolitan city; South West Nigeria Methods: This study was conducted with the aid of structured interview and questionnaires among registered community pharmacists in two Local Government Areas (LGAs) of Lagos State and thereports obtained were subjected to descriptive and inferential statistical analysis. Results: The feedback showed that almost all (136; 96.1) of the respondents could correctly define first aid care and also gave the correct aim of the provision of first aid care. Majority 126 (88.1) had been involved in the practice of life saving first aid care though only very few (13; 9.1) attended arecent training on FAC. However; their practice of FAC was affected by lack of adequate FA skills; the inability of most clients to pay for their bills; lack of cooperation from other members of the healthteam regarding referral of FAC cases in Lagos state; and lack of standardized skills acquisition protocols for the training of community pharmacists in the provision of FA. Conclusion: The community pharmacists in the two study areas demonstrated good knowledge offirst aid care but few applied this knowledge in their daily practice. The pharmacists indicated willingness to practice first aid effectively if properly trained. There is a need to sensitize all stakeholders to ensure that good quality first aid care services are made available in the community pharmacies

Potentials of Community Pharmacists to Improve Maternal; Newborn and Child Health

Background: With the high level of pregnancy; childbirth related and under-five deaths in Nigeria; achieving optimal maternal and child health has become the responsibility of all health personnel in a task sharing approach at all levels of care. Objectives: We assessed baseline status of community pharmacists' involvement in Maternal; Newbornand Child Health [MNCH]; described training intervention for community pharmacists on MNCH and assessed its impact on maternal and child health.Methods: Semi-experimental design; using multi-stage stratified sampling method was conducted in Abuja; Kwara; Abia and Edo States of Nigeria from June - September; 2011. Pre-tested questionnaires wereused to generate data on baseline activities of pharmacists. Two of the States were selected for trainingintervention while the remaining two served as control. A post-training MNCH activity level of the study and control settings was compared based on frequency of occurrence and Chi-Square analysis with the aidof Epi Info package.Results: Over 15 of community pharmacists reported seeing 5-10 women and 10-20 children daily. Agap in MNCH knowledge was observed. The training intervention improved MNCH knowledge in the study States (P 0.05); with post-training assessment showing a 40 average increase in the number of mothers and under-five caregivers counselled on key MNCH interventions.Conclusion: The baseline status of the community pharmacists' participation in MNCH revealed aconsiderable client load of pregnant and nursing mothers with under 5 years children in contact with the community pharmacists daily. Community pharmacists in MNCH interventions indicated a knowledge gap.The training intervention showed knowledge transfer and improved community pharmacists' position as promoters; facilitators and implementers of maternal; newborn and child health in Nigeria

A Profile of Current pharmacy Education in the Sudan

The first pharmacy college affiliated to University of Khartoum was established in (1963) with intake of only twenty students per year. This policy of admission continued with no substantial annual increase in the number of students enrolled in the college of pharmacy. However; after the revolution of higher education in the (1990) (s); the number of governmental and national pharmacy colleges has multiplied enormously. Today there are about thirteen pharmacy colleges with possibly more in the pipeline. It is true that expansion in higher education is a requirement for national development; albeit; a clear strategy should be envisaged whereby quality of the university graduate matters mare than number. Pharmacy graduates of the last ten years or so labored in an environment of severe shortages of qualified teaching staff and facilities. These graduates are understandably of low standards and consequently their contribution in health care will be poor

Evaluation of Pharmacists' Participation in Post-Admission Ward Rounds in a Tertiary Hospital in South-West Nigeria

Background: Many patients on admission have limited mobility and need physical examination by the clinical team. Ward rounds serve as an avenue for health professionals to meet and develop an integrated plan of care for the inpatients. Lack of representation for certain professional groups; including pharmacy; may adversely affect the range of opinions and therapies for patients. Objective: The study evaluates pharmacist's perception of and participation in post-admission ward rounds; at the Lagos University Teaching Hospital (LUTH). Method: All the 60 pharmacists covering various units of pharmaceutical services were administered a forty-two element structured questionnaire. Fifty (83.3) pharmacists completed the questionnaires. Descriptive statistics and chi-square were used to analyse the collated data. Results: Pharmacists had positive perception of their participation in ward rounds; some of whom were already involved in the exercise on a low scale. Peer reviews of patients' cases were frequently conducted and were usually dominated by the medical staff. The clinical role of the pharmacists is not clearly defined in respect to ward round. Their current impact in patient care activities during ward round is not significant. Conclusion: Pharmacists should be scheduled to participate actively in ward rounds; peer reviews and other professional activities; for optimum patient care. The hospital authorities should optimise the involvement of pharmacists in the paradigm shift towards pharmaceutical care; with a view to minimizing prescribing errors; cost of drugs and length of hospital stay. The use of preceptors should be explored

Pharmacists and Nurses Perception of Medication Errors in a Nigerian University Teaching Hospital

Purpose: To investigate the type and frequency of all medication dispensing and administration errors as perceived by pharmacists and nurses respectively; and the factors associated with such errors in a Nigerian university teaching hospital. Methods: The study was conducted at the Obafemi Awolowo University Teaching Hospitals; Ile-Ife and Ilesa; Nigeria. Data was collected by the use of pre-tested questionnaire administered to 35 pharmacists and a stratified sample of 130 nurses over a period of 2 weeks. The questionnaires were sorted and analysed. Results: The pharmacists that responded (80) cited incorrect drug; incorrect strength of drug (70) and wrong dose of drug (60) as the most common dispensing errors. Fifty percent of pharmacists put the estimated frequency of occurrence of these dispensing errors at 1 per 100 prescriptions dispensed. Most of the nurses (65) identified administration of wrong drug; administration of wrong dose (63) and wrong time of drug administration (57) as the most frequently occurring medication administration errors in the teaching hospital. All the pharmacists and 78of nurses identified excess workload as the most important factor contributing to errors in medication dispensing and administration respectively. Conclusion: The fundamental factor perceived to be contributing to errors in medication dispensing and administration was excess workload resulting from insufficient members of staff