The vision to utilise pharmacists’ clinical skills in GP practice is a practical one that could lead to a unified medicines optimisation service
Recently the Royal Pharmaceutical Society and the Royal College of General Practitioners issued a joint proposal that pharmacists should work in every GP practice in England. The initiative is not about having community pharmacies in GP surgeries but about making use of the pharmacist’s clinical skills, particularly for patients with long term conditions.
The initiative is aimed at taking the pressure off GPs where there is a growing workforce crisis and to help reduce medication related admission to hospital.
In Wolverhampton this vision is already a reality and has been for several years.
As in many health economies, pharmacists and pharmacy technicians in Wolverhampton, previously employed by the primary care trust, have been working in GP surgeries for over a decade. These primary care pharmacy teams have worked with individual practices to maximise generic prescribing, reduce waste and promote the most cost effective use of medicines.
This work has involved educational programmes, working with practice computer systems, auditing prescribing practices and benchmarking.
‘The pharmacists review patient’s treatment amending where appropriate, including de-prescribing’
There are currently nine pharmacists and three pharmacy technicians in the Wolverhampton primary care pharmacy team. Over recent years the focus of the work of the team has shifted to a much more clinical, patient facing service.
All pharmacists are very experienced (AFC band 8), and qualified independent non-medical prescribers, able to run clinics in GP practices for patients with long term conditions such as hypertension, respiratory and cardiovascular disease. In these clinics the pharmacists review patient’s treatment amending where appropriate, including stopping medication (de-prescribing), to maximise the benefits and reduce risks to patients from medicines.
It is known that up to 50 per cent of medicines prescribed for long term conditions are not taken as intended by the prescriber, so our pharmacists seek to understand the patient’s experience of their medicines and find regimens that fit with the individual’s lifestyle in order to facilitate adherence. Patient education about their condition (eg blood pressure, know your numbers), their medicines and the provision of a patient management plan (eg asthma action plan) may all form part of the consultation.
In addition to the direct patient care activities the primary care pharmacists work with GP practices delivering educational programmes on therapeutics and medicines optimisation to a variety of primary care health professionals. The technicians have worked with care home staff for some years to improve medicines ordering, storage, and reduce waste.
They now also deliver training on clinical issues such as inhaler technique, and managing specific conditions, constipation for example. The pharmacists have also been working with a care of the elderly consultant to review medication for nursing home patients with a specific focus on de-prescribing where appropriate.
‘The hospital pharmacists can email the primary care pharmacy team with details of high risk patients’
In 2013, with the dissolution of PCTs and formation of clinical commissioning groups with no provider function, it was agreed with the local acute hospital, Royal Wolverhampton NHS Trust, that the primary care pharmacy team would transfer employment to the hospital pharmacy, and the work plan delivered through a service level agreement between the CCG and the hospital. The key drivers for this arrangement were to retain the team’s “local intelligence” and facilitate greater partnership working with the hospital pharmacy team, particularly when patients are discharged from hospital.
GPs already receive a discharge letter electronically within 24 hours of one of their patients being discharged from the hospital. In addition to this the hospital pharmacists can email the primary care pharmacy team with the details of any patient discharged who they consider “high risk” in relation to their medication.
As the primary care pharmacy team are hospital employees they can log on to the trust’s web portal and view the patient’s full clinical details. They will then arrange an appointment with the patient post discharge to review their medication and take action to minimise any risks.
This is helped by the fact that there has been a joint primary/secondary care formulary in Wolverhampton for a number of years.
There are other benefits to having a single pharmacy team working across primary and secondary care such as wider training opportunities for junior hospital pharmacists, pre-registration and undergraduate pharmacy students on placements. This is particularly important if we are to grow a pharmacy workforce with the necessary skills to deliver the joint RPS/RCGP vision.
This arrangement has also created a clear separation between CCG medicines optimisation pharmacists working as commissioners at a population level and the pharmacists and technicians working in GP practice as a service provider to implement the medicines optimisation vision at patient level. It also gives assurance to the commissioner that they are employed directly by an organisation registered with the Care Quality Commission and all that provides.
The “Wolverhampton experience” demonstrates that the joint RPS/RCGP vision can work in practice for patient benefit and, if the organisational arrangements are right, deliver a unified medicines optimisation service across the whole health economy.
Ray Fitzpatrick is clinical director of pharmacy at Royal Wolverhampton NHS Trust and professor of clinical pharmacy at Keele University