Evidence grows for clinical pharmacists in primary care
There are now over 1,000 full time equivalent clinical pharmacists working in England, with funding available as part of primary care networks for some time. Research published so far in 2022 builds on evidence from the English pilot as well as from around the world, which provides an even more convincing case for the value that they can bring, whilst recognising the trade-offs in employing them versus other ways to spend limited funds.
Evidence of reduced pressure on GPs
Having clinical pharmacists working in primary care was piloted in England in 2015. A 2018 evaluation of the pilot conducted by the School of Pharmacy at the University of Nottingham, alongside others, included observational studies, one to one interviews with staff and patients, as well as patient focus groups and case study site visits. It acknowledged the value clinical pharmacists can bring to practices, from reducing waiting times for appointments to saving GP locum costs. It also included routine service data from 12 practices.
The evaluation found that clinical pharmacists could significantly increase patient appointment capacity and reduce pressure on practices. This was driven in large part through medical reviews and that in turn released capacity for GPs. Prescribing by clinical pharmacists was another upside.
Eagle-eyed readers of the press release will have noticed that the evaluation was undertaken at a time when there was already strong support for clinical pharmacists in primary care and a commitment to increase their number to 2,000 by 2020/21.
Evidence of reduced pressure on emergency services
The pilot evaluation results are consistent with a 2019 systematic review that looked more widely at the available evidence, which found that pharmacists in primary care reduce GP appointments. The review drew on 28 publications from the US, Canada, the UK, Sweden, Spain, Brazil and Singapore.
There was good news too for the wider NHS, with evidence that pharmacists in primary care reduced the use of emergency care. No impact was found for hospitalisations, but there was some evidence for savings in healthcare overall and in the cost of medicines.
Systematic reviews like this are often seen as compelling because the method should ensure a comprehensive and unbiased review of the evidence.
Evidence of positive views of patients and GPs
Although by no means in a comprehensive review, more evidence has been emerging about acceptance and the value of pharmacists in primary care. Analysis of patient focus groups with 34 UK patients – the work was done in 2016 but the results were only published this year – reported high acceptability levels and a positive impact of pharmacists on use of medicines. The patients also liked the longer appointment times and didn’t feel rushed. For the NHS, there was a route to value too, through improved patient self-monitoring and self-care.
A qualitative evidence synthesis of 19 studies has brought together evidence on the views of GPs. Reassuring, if perhaps predictable, this found that GPs find pharmacists useful when optimising complex patients’ medications.
Saving the best for last is a recent analysis that draws on annual data on staff in 6,296 English general practices between 2015 and 2019 and which is linked to 10 indicators of quality of care covering accessibility, clinical effectiveness, user experiences and health system costs.
Regressions were run to explore the impact of GPs, nurses, health professionals and healthcare associate professionals on these indicators. Pharmacists are one of the NHS roles in the healthcare professionals group, alongside physiotherapists, physician associates, paramedics, podiatrists, counsellors, occupational and other therapists and other allied health professionals.
What marks this analysis out is the comprehensive nature of the data – it’s almost all GP practices in England – as well as the range of indicators studied, which will tick the boxes of all stakeholders. And regression analysis can explore associations quantitatively, providing a more objective approach to evidence generation than qualitative work.
The quantitative analysis highlights what many would expect: higher numbers of GPs and nurses are positive for accessibility and user experience. Higher numbers of healthcare professionals – which include pharmacists – are associated with better prescribing. More staff means costs go up too, of course. The findings raise questions too. The analysis found that the introduction of new roles was associated negatively with patient satisfaction.
The research also highlights an important limitation. New roles, such as pharmacists in primary care, are still small in overall numbers, so it’s hard to identify contributions for specific roles outside of GPs and nurses. Identifying the precise value of pharmacists is, basically, not yet possible.
Even as the evidence points to the value of pharmacists, reality means that there are trade-offs. Decisions about skill mix – and just how many pharmacists to employ – are driven by relative costs as well as the benefits different professionals can bring. Employing a pharmacist has to be weighed up against employing a nurse, for example.
Supply is also a factor. The wider impact on the pharmacist workforce has been raised, although the opposite argument has been made too that even with more pharmacists working in primary care there are more than enough, given higher numbers entering the GPhC register.
Even with new questions raised by the research, the case for pharmacists in general practice is increasingly underpinned by evidence that points to how much sense it makes to choose a pharmacist.