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19 December 2018
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To kick off our series on the wider primary care team, Rachel Carter speaks to four practice managers about employing a clinical pharmacist and the positive difference it has made to their practice and patients.
The idea of employing clinical pharmacists in general practice has been bubbling under the surface for a long time – but it has really come to the fore in the past few years, after a funding commitment in the General Practice Forward View to support an extra 1,500 pharmacists working in practices by 2020.
NHS England’s Clinical Pharmacists in General Practice programme started with a pilot in July 2015, and as of this September 810 full-time equivalent pharmacists had been supported into practice roles. Research has shown that employing a practice pharmacist can have a positive impact on the business in a number of ways.
In September, a study published in the British Journal of General Practice did, for example, demonstrate that having a clinical pharmacist in the team can save around five hours of GP time a week, and help boost staff morale.
The study, carried out in Scotland and incorporating 16 practices, named the improvement of prescribing processes and enhanced patient safety as positive impacts of having an in-house pharmacist.
To better understand the benefits pharmacists can bring, we spoke to four practice managers – who have employed pharmacists independently and through the NHS programme – about their experiences.
City View Medical Practice, Leeds
Victoria Keys, practice manager
City View Medical Practice was ‘quickly sold’ on the benefits of adding a pharmacist to its team, says practice manager Victoria Keys. They started out with a locum pharmacist, before joining the Clinical Pharmacists in General Practice programme when it became available locally.
‘At the time, we were running a lot on locum staff, so all the administrative work and prescriptions were going to the permanent GPs and they were overloaded,’ Ms Keys says.
‘We were a group of three practices and took on three pharmacists but one later pulled out of the programme so we’ve ended up with two, and have been able to put both to full use.’
The two pharmacists have different backgrounds: one previously worked in community pharmacy; and the other in medicines management at a CCG.
She says that being flexible is integral to making the programme work, because pharmacists come from different backgrounds with different skill sets, so ‘you have to work with the skills of the individual and shape the role so that it suits the practice and the pharmacist.’
The GP surgery is now in its third and final year of the NHS scheme, which sees practices receive a decreased level of funding for the pharmacist role over the period.
The pharmacist role at City View includes undertaking audit work for prescribing antibiotics and drugs that require regular monitoring, face-to-face medication reviews with patients, long-term medication reviews – particularly around hypertension – and prescription queries.
‘Medication reviews are a huge thing because we are in an area with a big patients churn and every new patient needs one, so that has made a big difference,’ Ms Keys says. Reducing the GP workload was one of the driving factors behind taking on clinical pharmacists, and this has paid off, Ms Key says.
In 2017-18, the pharmacists completed 935 medication reviews, saving 389 GP hours. They also carried out 1,202 medication requests, which saved another 200 hours. For patients, the main benefit has been that they can see someone faster than if they were waiting for a GP.
The pharmacists are very thorough, Ms Keys explains, and can talk patients through medication reviews in detail because they have the time. She adds that the external support and training provided by the NHS programme has been ‘useful’ and the practice has ‘never regretted’ taking on the two pharmacists.
Top tip for other practices
‘Be flexible and work with the skills of the individual to mould the role together.’
Lea Vale Medical Group, Luton
Heidi Newton, practice manager
Lea Vale Medical Group first looked into employing a pharmacist in 2016, after identifying a need for more knowledge and confidence in supporting diabetic patients who had been discharged from hospital with complex insulin medications.
‘Specialist diabetes nurses are really rare, so we thought we’d have a look at a pharmacist,’ says practice manager Heidi Newton. Around that time, many GPs retired from the practice, so money was available for recruitment.
The first step was to hire an independent prescribing pharmacist, who could manage the diabetic patients and the role ‘just really grew from there,’ Ms Newton says.
In 2017, the practice recruited another pharmacist who had secondary care and community experience, to assist with discharge summaries and medication queries.
‘We realised that there were so many medication queries coming through from patients and from clinicians who needed her help when they were trying to understand contraindications and the complexity of some medications,’ she says.
The practice has now expanded its pharmacy team to include another pharmacist with community experience and a pharmacy technician.
Ms Newton says one of the main benefits of employing pharmacists has been their degree of medication expertise. ‘For patients that adds a level of safety and we know we’re compliant with our monitoring. And for clinicians, they always have that expert in-house to refer to.’
The pharmacy team has also helped to reduce the GP workload, such as the pharmacy technician and one of the other pharmacists hosting what the practice refers to as a ‘full list’ – speaking to 30-40 patients a day to handle medication queries.
‘The GPs are only seeing about 15-20 discharge letters a day now and don’t have to action the complex medication or wait on the phone to a consultant,’ Ms Newton says.
Lea Vale is due to take on one more pharmacist, this time through the NHS England programme.
‘We thought that as we already had pharmacists in post we’d get those from the programme out to the other practices [in the group],’ Ms Newton says, adding that the practice will continue to employ the team of five.
‘We’ve done this without national funding and have really seen the benefit,’ she says.
‘It would be a shame if practices that have [solely] gone through the programme come out of it once the funding ends – pharmacists can free up so much capacity and they bring a level of safety that primary care traditionally doesn’t have.’
Top tip for other practices
‘Don’t get bogged down in the job description – wait until your pharmacist is in practice, see where their strengths are and grow the role organically’
Irwell Medical Practice, Lancashire
Irwell Medical Practice wanted a clinical pharmacist who could ‘hit the ground running’ and have an impact on reducing the GP workload, says strategic manager Pauline Aspinall.
The practice opted for recruiting independently, rather than going through the NHS England programme, as it felt this would be the most cost-effective way in the long-term, Ms Aspinall says. She adds that ‘we were very lucky that we knew and had already worked with the pharmacist we employed as she’d worked for the CCG.’
The pharmacist who came on board already had an independent prescribing qualification and was put to work setting up clinics to deal with medication queries. She also completes face-to-face medication reviews with patients, makes home visits when necessary and handles any medication changes when patients are discharged from hospital.
‘All of this would have been done by the GPs – so she has reduced their workload significantly,’ Ms Aspinall says. ‘I had a few partners who were sceptical in the beginning and weren’t sure it would make any difference, but now they all wonder how we coped without her before.’
Ms Aspinall says the key benefit for patients is receiving a more holistic service. ‘They are getting a more timely response and she is able to pick up things like interactions with other medicines or see where a person would be better on a different drug.’
‘That’s a definite benefit for the patient and we’ve had some fantastic feedback,’ she says. From the GPs perspective, the pharmacist is an ‘excellent link between the clinical and the pharmaceutical’ and having that extra input has been beneficial, she adds.
The pharmacist has also helped upskill the practice’s prescription team, providing training on which medication queries could be passed on to her rather than to a GP, and creating a set of guidelines for prescribing diabetes medication.
‘Having the pharmacist here has given them that extra dimension,’ Ms Aspinall says. Going forward, the position will definitely continue to be funded, she explains, adding that ‘we can only see it growing – there’s so much a pharmacist can achieve within the team.’
Top tip for other practices
‘Ensure the pharmacist is an independent prescriber and have a clear idea of what would benefit your practice’
Parchmore Medical Centre, Surrey
Teresa Chapman, practice manager
After an unsuccessful application to the NHS England programme, the team at Parchmore Medical Centre’s were so convinced they needed a pharmacist that they ‘decided to go it alone’, says practice manager Teresa Chapman, and they advertised the post in August 2016.
The practice had been struggling with a shortage of GP and workload audit confirmed ‘what they already knew’ – that many GP duties ‘could be handled by another team member’, Ms Chapman adds.
‘We wanted to get someone in to support the GPs with the prescribing work and be a “go-to person” for expertise,’ she says. ‘The reason we recruited our pharmacist was that she had lots of hospital and practice experience as she’d worked for a clinical commissioning group in another area.’
The pharmacist didn’t have an independent prescribing qualification when she started, so the practice supported her in getting the qualification, which she has since completed. Her role currently includes dealing with all prescription queries and changes to medication after a patient’s hospital discharge.
After completing her prescribing qualification, the pharmacist also specialised in hypertension and now runs some of the practice’s hypertension clinics. She also undertakes thorough reviews with complex patients who are on a number of medications, Ms Chapman explains.
‘She particularly focuses on people with 10 or more medications; checking compliance, understanding whether they still need to be on all of them, and making any adjustments.’
The expertise the pharmacist brings to the team has been particularly valuable, Ms Chapman says, on issues where the GPs have more limited knowledge.
‘Sometimes queries come through for dressings that you’ve never heard of, for example, and she will do the research, make any checks necessary to ensure it’s in line with our prescribing protocols and generate the prescription,’ Ms Chapman says. ‘The GP needs to just check and sign – it’s a big time-saver.’
Saving time and freeing up capacity for GPs has ‘without a doubt’ been one of the main benefits of bringing a pharmacist on-board, Ms Chapman says, but the extra knowledge she contributes has also meant there is somebody to go to for ‘all the team’.
‘If a patient rings up in the morning and they’ve got a medication query, they [would normally be] in the same queue as people with acute problems. With our pharmacist now, she’ll ring them back that morning.’
Ms Chapman says the practice also wanted its smaller site to benefit from this support, so decided to reapply for the programme – this time successfully – with a second pharmacist joining in September.
‘My advice to practices who are unsure about it is that once you try it you wouldn’t go back.’
Top tip for other practices
‘If you can get someone with a bit of experience, even hospital experience, it helps with getting to grips with the work’