Many more practices are taking on a clinical pharmacist as part of their practice team. The NHS England
national pilot scheme has been a massive driver for this. The challenges of GP recruitment mean more practices are looking at new ways of working and widening the multi- disciplinary team. Bringing a pharmacist into the practice has huge benefits.
The practice where I’m based in Cheshire has a list size of 23,500 patients, and took on a pharmacist nine years ago to improve quality for patients and to share the workload. It began as a three-year pilot scheme with the primary care trust to employ a full-time pharmacist. The role had to be funded through prescribing cost savings, and had to offer more than the traditional medicines management role.
The practice believed that having a pharmacist on site every day would help drive quality improvement in prescribing, benefit patients through improved response to medicines- related queries and reduce GP workload. At the end of the three years, the pilot had exceeded the funding requirements and in the following six years, the role continued to develop. The financial commitment from the practice built up over this time and the position is now full-time and fully practice funded. An additional full-time pharmacist has recently been employed as part of the national pilot.
Practices will have different priorities and needs for a pharmacist’s input. At Ashfields we see the pharmacist’s role being split into main areas.
1. Acute patient contact
The pharmacist is the first clinical point of contact for patients with medication queries, either presenting at reception or over the phone. The queries might be new medications side-effects, carers reporting that patients have not taken their medication correctly, or the unavailability of a medicine.
The pharmacist also deals with safety alerts and medicine discontinuations, allowing us to manage the process systematically and reducing GP workload.
Pharmacists can advise patients on self-limiting conditions.
In some practices the pharmacist performs a telephone triaging role and sees patients for assessment of some conditions.
The pharmacist can also support the practice manager by helping to respond to complaints or conflicts related to medicines.
2. Treatment
As an independent non-medical prescriber, I run a weekly clinic for long-term conditions. At present this covers hypertension, cardiovascular disease, rheumatoid arthritis and osteoporosis. The clinic improves patient access and releases GP appointments. The benefits will increase as our second pharmacist also becomes a prescriber.
I review blood test results for patients I see and also for patients attending for a cardiovascular risk review, which reduces GP administration.
I’m also involved in reviewing the Quality and Outcomes Framework (QOF) registers that have a medicines element, supporting the practice QOF achievement.
We are setting up a new daily pharmacist drop-in clinic, which will not only improve our response time for dealing with patient queries related to medicines, but will also support our practice nurses. If our nurses see patients who need a medication change, they will be directed straight to the pharmacist prescriber to implement the change. This will reduce workload for both the GPs and reception as the patient will leave with the change completed, and won’t have to wait for a follow-up phone call later in the day. This should therefore also be a better patient experience.
At Ashfields, our pharmacists are involved in unplanned emergency admission prevention, contacting patients after discharge as part of this enhanced service.
3. Repeat prescribing
Repeat prescribing is a huge part of primary care administration. As a practice pharmacist, it is a priority to supervise and review systems to ensure repeat prescribing is safe. Developing written policies supports this.
I have carried out process mapping to streamline our process while maintaining quality. I am a member of the practice quality improvement team.
We have recently been focussing on our patient contact at reception and identified through data collection that 27% of patients presenting at our front desk have a medicines-related query.
Ensuring we have the right systems for our repeat prescribing system is helping to reduce this percentage and also reducing queues at reception, with the aim to maximise patient satisfaction.
Reviewing medication to ensure it is on repeat whenever appropriate also reduces the number of queries at reception.
We are implementing repeat dispensing in partnership with our community pharmacy colleagues, identifying patients who may be suitable. Moving our stable long-term condition patients to repeat dispensing will reduce the number of repeat prescriptions generated, signed and collected each day.
Our practice has a highly skilled team of prescription clerks who perform rigorous checks to ensure prescriptions are issued safely. As a pharmacist I have provided written guidance for therapeutic drug monitoring which improves safety by empowering our team to implement medication monitoring, without the need for intensive GP input.
A large part of the pharmacist role at our practice is reconciling medication for patients discharged from hospital and contacting them to discuss any changes. This saves our GPs administration time as they don’t have to update the medication after discharge and any discrepancies are dealt with directly by the pharmacist. This is a quality service for our patients that can address concerns they may have and reduce the need for follow-up appointments with the GP. As the experts in medicines, pharmacists are able to perform medication reviews, either on screen, by telephone or face to face. I review and authorise medication for new patients, ensuring all the monitoring is in place and contacting them to discuss changes to medication if it does not conform to our practice formulary. Getting the formulary choices right at the first prescription for a new patient is much easier than contacting them at a later date to switch. Medication review for care home and housebound patients is another part of the role. We do home visits for this group of patients.
Working with our community pharmacies is extremely beneficial and the practice pharmacist is a first point of contact for our local pharmacists to discuss issues and forge good working relationships. All medicines use reviews are sent to me so I can take action from the recommendations and feed back any outcomes.
Communication is vital and we aim to keep our pharmacies informed of changes to our policies. We are currently reviewing our processes for the monitored dosage system prescriptions and are working with local pharmacies to streamline this process. It’s also important to have good working relationships with the local medicines management team and we achieve this through regular meetings with our pharmacy technician and by being their first point of contact.
4. Education and audit
I run regular education sessions for clinicians at our protected learning time and clinical meetings. This can involve auditing prescribing against
current guidance, identifying areas for improvement and facilitating discussion in a therapeutic area.
This results in agreement of best practice and formulary choices across all clinicians, which helps make care consistent across the practice. The discussions allow all clinicians to peer review audit data and improve the overall quality of care.
When a new prescriber joins the practice I meet them to share our agreed formularies and ways of working.
I also provide education sessions for our administration staff, registrars and medical students. This improves staff knowledge of medicines and the repeat prescribing system. I have recently provided training to the administration team on our local minor ailments scheme with the intention of signposting to it more regularly.
Joanne Goodwin, Senior Clinical Pharmacist, Ashfields Primary Care Centre, Sandbach, Cheshire
