Collaborative working between GPs and community pharmacists improves outcomes for their businesses, and certainly for patients, so why are we still not seeing more of it?

Ask most GPs and pharmacists if they think there is scope for closer working relationships between the two professions and they invariably say yes. Ask them why they’re not doing it, and they’ll list all kinds of barriers, from time and money, to professional rivalry and lack of any contractual compulsion. 

It’s an age-old debate that seems to have been chasing its own tail for years, so is there a way to move it further towards a model of working together locally, with confidence and as
professional equals, for the sake of patient care if nothing else?

From a GP perspective, Peter Nicholas, managing partner at Hildenborough & Tonbridge
Medical Group – a large multi-site GP practice in Kent that serves a population of more than
16,000 patients – certainly sees potential for collaboration, but says, ‘While the GP and pharmacy contracts continue to run in parallel but separately, there are not obvious areas to bridge the gap between them to enable more collaborative working. It is hard to say what
would need to change, whether a contractual shift or a cultural one, so I think this is something that may take a while to move forward.’

For Mimi Lau, Numark’s director of pharmacy services, it has to be a two-way process. ‘The
relationship between pharmacists and GPs is improving and there are many examples of how
close collaboration between the two is improving patient care. There are, however, still too many examples of where there is no desire to work together. In some cases there is a destructive relationship where GPs seek to compete with local pharmacies by establishing their own pharmacies, or directing prescriptions in favour of particular pharmacies. And it has to be said, in some cases, pharmacists are failing to communicate with their local practices, possibly fearing rejection.’

Echoing Mr Nicholas, another barrier, according to Ms Lau, is that ‘the UK pharmacy contracts do not contain any requirements or incentives for pharmacists to engage with GPs, or indeed any other healthcare professionals’, so while she says close collaboration makes sense, she believes ‘progress will inevitably be slow and patchy where there is no incentive or other driver to encourage it’.

Pharmacy Voice is a loud advocate for closer working between GPs and pharmacists, but chief executive Rob Darracott also picks up on the same pressure points between the two areas, saying, ‘Issues such as prescription direction, which continues to harm some businesses, and the current GP-centric nature of commissioning can impact on the ability to support stronger ties between the professions. Although strong working relationships and joint working are possible under current arrangements, we believe that changes to commissioning structures are necessary if a new integrated model of care is to reach its full potential for patients.’

Time for teamwork

So what exactly does collaborative working look like? For Dave Branford, chair of the EPB and chief pharmacist for Derbyshire Mental Health Trust, it’s clear: ‘For me, it means simply where the pharmacist and the GP work as a team.’

He thinks that the current manpower crisis in general practice could be a catalyst for more collaboration because ‘GPs are desperate for help from people who are able to take away their problems and deal with their difficulties. A lot of these problems are to do with medicines, and the more GPs become overwhelmed by work, the more problematic that is going to become.’

The EPB’s five pharmacy campaigns – under a programme called Shaping Pharmacy for the Future – are all focused on this, with pharmacists working in A&E, on common ailment schemes, pharmacists working with GPs, pharmacist-led care of long-term conditions, and in care homes, all aimed at getting the pharmacist to be part of the wider team.

Teamwork is obviously a given, but Alastair Buxton, PSNC’s head of NHS services, says that individual roles within any collaboration have to be clearly mapped. ‘Ideally, collaborative working would mean GPs and pharmacies working together to provide seamless care to patients – each provider would have defined roles within shared care pathways, and transfer between the two would be fast, easy and backed by technology,’ he says.

Benefits all round

For Mr Buxton, these more defined roles of care would benefit both GP practices and pharmacies. This would lead to more joined-up care for patients, and ensure that the NHS was making best use of resources with all health professionals working together to achieve the best outcomes.

An example of this in action is the Community Pharmacy Future project, says Mr Branford, ‘which was undertaken by four of the big multiples within a couple of areas of medicines use, but as the project developed it became more encompassing, improved relations with local GPs, and involved more and different pharmacy organisations, and really built the collaboration.

‘I talked to people involved in the project in Lancashire and all of them said it transforms the
job for everyone involved. For example, pharmacists find their job more satisfying as there are fewer errors and less waste. It also takes an enormous workload away from GPs, which is a weight off their shoulders, and delivers a far better service to patients, who are more likely to get their medicines, with fewer errors.’

Building bridges

If this is the case, what is holding the process back? According to Mr Buxton, our straitened economic times are part of the problem.

‘Relationships between GPs and community pharmacies can be negatively impacted by a number of factors. In some areas we have seen GPs behaving territorially over services, for example raising objections to pharmacy flu vaccination schemes in order to protect their own services. This sort of protectionism is perhaps understandable given how tightly finances are being squeezed across the NHS, but it can be a significant block for some services.

Relationships can also be delicate where GPs perhaps do not understand pharmacy services and believe pharmacies are duplicating the efforts of the practice. The reformed NHS has seen some relationships strained as GPs have taken on commissioning powers as well as being providers.’

Mr Branford thinks a lack of ‘face time’ also doesn’t help. ‘The primary barrier is that at the moment community pharmacists and GPs are in different places, and the amount of contact between them is relatively small. Much of that contact will be around problems, with the result that the community pharmacist can appear to be opinion causing more work for the GP or pointing out that they’ve made mistakes.

The second problem is that we’ve moved increasingly towards most pharmacies only having one pharmacist in them. The solution would be to have collaborative working between pharmacies and the GP using a pharmacist based at the GP surgery who works closely as a liaison between the two.’

In-house help

In fact, there is a lot of activity at the moment around embedding pharmacists in GP surgeries.

This month the EPB is launching the second of its five campaigns, which is around pharmacists and GP surgeries. ‘We are proposing one model where a pharmacist would work as a member of the GP surgery staff in the key role of collaborating between other community pharmacies within the area,’ says Mr Branford, ‘and another model is where local pharmacists are part of the management of an area of therapeutics, and again have a pharmacist within GP practices as a liaison.’

‘Another way to collaborate would be for all the community pharmacies in an area to get together more and work as a team with the GPs. Local pharmacy networks have been trying to do that but the word ‘federations’ is not seen in the world of pharmacy as a very helpful term – although a number of independents here in Leicester, where I am based, have come together to form a federation and have employed someone who is a liaison with GP practices.’

The RPS has worked with the NHS Alliance to produce a new report on the role that pharmacists could play in general practice (www.rpharms.com/promoting-pharmacypdfs/
nhs-alliance-pharmacists-in-generalpractice.pdf), following a roundtable discussion last autumn, which explored this opportunity.

According to Mr Darracott, Pharmacy Voice is starting to see evidence that ‘the ongoing implementation of the Summary Care Record can also help closer working between GPs and pharmacy teams, [because] access to online patient records ensures that pharmacists and GPs both have maximum time to spend interacting with their patients and the public, rather than sorting through old, paper, patient records or making phone calls to busy surgeries.’

Start talking

With all this in mind, how can pharmacists start to reset their working relationships with GPs?
Mr Buxton says the key is to think about how best to frame your approach – ‘talking to them about ways in which you might be able to help them, and asking them what you could do differently may be better received.’

Many pharmacists have asked to go along to practice meetings, rather than asking for extra
time from GPs. ‘Attending these meetings and listening to the challenges the doctors are facing may be all that is needed as a first step; offering suggestions for how you could help may follow, and then offering to proactively spend a few minutes talking them through initiatives at your pharmacy and explaining how those could benefit their patients or workload may be a good way in.

You could also try talking to your LPC and see if they can co-ordinate with the local LMC – joint training has been very successful in some areas, allowing GPs and pharmacists to meet in a less formal setting to learn and develop together.’

Mr Darracott stresses that it is vital to remember that it is about integrated care, ‘not about one profession being subsumed into another. Both have their strengths, in location and expertise, and it is important we play to these, ensuring we always put the patients’ health first.’