A small number of pharmacists have been working in GP practices for years, delivering a range of services under a number of different practice models, but these roles have always been the exception rather than the norm. Now the English Pharmacy Board is proposing that every GP practice could have its own clinical pharmacy team, in the same way that every hospital ward expects to have a pharmacist and technician to manage medicines.
‘We think that pharmacists offer an opportunity to help the current GP manpower crisis, so there’s an opportunity to offer the option of pharmacists in GP surgeries as a way of transferring some of the workload from GPs around medicines to pharmacy teams,’ says EPB chairman David Branford. The EPB was preparing a briefing document on the subject in early August, which it planned to ‘promote widely across the next period’. It had already had preliminary discussions with the Royal College of General Practitioners and NHS England.
Pharmacists are already practising from surgeries under a wide range of models, and the EPB does not favour any particular system. ‘There are huge opportunities to enable pharmacists to work in GP practices. We don’t mind the organisational aspects, we’re just waving the flag. Pharmacists in surgeries – yes please.’
GP surgeries could also be a useful destination for the excess numbers of pharmacists qualifying. ‘We have to find jobs for an extra 10,000 pharmacists coming onto the register over the next few years. This is fantastic opportunity for a key clinical role.’ The proposal would also benefit nearby community and hospital pharmacists. They should find it much easier to resolve medicines queries if they could speak to a pharmacist at the surgery. We see the role as a facilitating one for the whole profession.’ Mr Branford suggests a number of potential funding solutions for the new role. For example, GPs could use savings made from prescribing advice or other pharmacist-led initiatives to fund a pharmacist in their practice. Alternatively, CCGs may be persuaded to make the funds available on safety grounds if pharmacist input were shown to cut prescribing errors. Or practices that fail to recruit sufficient GPs could use that money to ‘re-skill’ the practice by employing a pharmacist instead of a GP.
EPB members apparently have mixed views on the matter, with Sid Dajani, for one, ‘totally against’ the idea. ‘What we need is a clinical pharmacist role in the community. The whole of the strategy for the NHS for the past 15 years has been to keep patients out of surgeries. Where better than in their local community pharmacy? For us to go back to surgeries is like going back to the 1980s, where pharmacists went to GP surgeries and just became number crunchers.’
Patients should visit community pharmacies, acting as the ‘hub and spoke’ for clinical services, says Mr Dajani. All the evidence points to that being the most effective model, he says. And practice-based pharmacists are less accessible because surgeries are not generally open at weekends or evenings.
The idea of using some of the 10,000 oversupply of pharmacists is simply a “ploy”, says Mr Dajani. More funding and commissioning for pharmacists in pharmacies is needed instead, which would create more demand for pharmacists.
‘This is not only a bad idea, it’s a dangerous idea. GPs could end up commissioning their own pharmacists, diverting resources and intellectual capacity away from the community. Our policy is patient-centred care, not GP-centred care. The GP is just part of a jigsaw puzzle, and care should follow the patient. If there’s an excess of pharmacists, put them in pharmacies and get them commissioned.’
Basing more pharmacists in surgeries is an opportunity for professional collaboration, says Dr James Davies, planning and policy manager at Pharmacy Voice. ‘This can lead to improvements in medicines management, which could be the focus for more joined up, integrated care for patients, as long as that recognises and utilises all the interactions patients have with health professionals effectively.’ But there is a balance to be struck, particularly in a cash-strapped system, says Dr Davies. Every one of the 438 million annual health-related visits to community pharmacies is an existing opportunity for care. And interventions such as MURs and NMS are only the beginning for medicines optimisation services within the pharmacy network. ‘This network, with investment from outside the public purse, is also increasingly recognised as vital for wide, local, interaction with the generally well population in tackling public health issues, which can sit uncomfortably in GP surgeries where people go when they are ill.’
Dr Davies warns of potential commercial conflicts of interests. Practice-based pharmacists could be used as a “fig leaf” of professional input for the new type of prescription direction schemes that have appeared in the past few months.
‘GP surgeries could effectively use the expertise of pharmacists, particularly as we look to a future with more pharmacy graduates. But it is important that any new initiatives build on the work the community pharmacy team does, day in, day out, to keep the public safe, use their medicines more effectively, respond to their urgent care needs and contribute to their overall health.’ A vote in favour Dr Keith Ridge, England’s chief pharmacist, recently praised practice he’d seen at the Old School Surgery in Fishponds, Bristol, in his NHS England blog. This practice has an independent pharmacist prescriber as a partner in the practice, as well as a community pharmacist on-site.
This seems to give the GPs the confidence to, for example, use innovative medicines such as the novel oral anticoagulants, not just safely and appropriately, but also more frequently than other practices in the area, says Dr Ridge. This reduces attendances at warfarin clinics and keeps patients safer, he says.
Dr Ridge was particularly impressed with how the on-site community pharmacist supports patients with long term conditions, with around 60 per cent of prescriptions run through a repeat dispensing scheme. The pharmacist spends a lot of his time talking to patients, enabling him to optimise medicines use. ‘This is not only good for outcomes, but also reduces waste. And it’s also good for drug expenditure, with the practice having prescribing/dispensing costs considerably less than the national average,’ says Dr Ridge. He described the model as, ‘not only great care, but also great clinical relationships within and across professions that create headroom for innovation’.
But arguments for basing pharmacists in surgeries ‘ignore the fact that the action is in the pharmacy,’ says John D’Arcy, chief executive of Numark. And this links to the reason that pharmacists want to continue dispensing – it brings people to them. ‘What’s the big pressing need to be in the surgeries?’
As well as the lack of appointments and ease of access, pharmacies are an ideal place for pharmacists to dispense medicines advice says Mr D’Arcy. ‘Pharmacists’ raison d’être is helping patients get the best from their medicines.’ Additional roles such as flu vaccination, blood pressure monitoring and so on, are also better carried out in the pharmacy, he says.
While sitting in on practice meetings can be of benefit to pharmacists, GPs are likely to have little time to interact directly with a pharmacist. Access to patient records may have been an argument for practice-based pharmacists in the past, but this is becoming less important as electronic links improve. Pilots of read-only access to the summary care record are a step in the right direction and will help link pharmacy to the wider NHS.
If more pharmacists are needed to do a job, that’s probably needed around the pharmacy. So we should be thinking about how we get resources for that
A different approach should be taken to oversupply, which is a business issue, says Mr D’Arcy. ‘First you should set out what you want to achieve, then what resources you need to deliver it. If more pharmacists are needed to do a job, that’s probably needed around the pharmacy. So we should be thinking about how we get resources for that.’ For example, flu vaccination makes a strong case to argue for additional resources because it is ‘born out of the accessibility of the pharmacy network’.
Although Mr D’Arcy doesn’t have a preferred operational model for practice-based pharmacists, he is wary of potential pitfalls. ‘What we don’t want to happen is another tier of pharmacy. If they’re not speaking to anybody else they could end up operating in a vacuum.’
There should be some overarching objectives because GP and pharmacy contracts are separate, so there is no joined-up working and there could be overlap and duplication, potentially with a degree of “anarchy”.
He suggests designating responsibility for elements of care and identifying long-term aims so that, for example, community pharmacists could manage all minor ailments cases, with GPs referring these patients to pharmacists to free up their time.
For ‘We have to find jobs for an extra 10,000 pharmacists coming onto the register over the next few years. This is fantastic opportunity for a key clinical role.’ David Branford
Against ‘The whole of the strategy for the NHS for the past 15 years has been to keep patients out of surgeries. Where better than in their local community pharmacy? For us to go back to surgeries is like going back to the 1980s, where pharmacists went to GP surgeries and just became number crunchers.’ Sid Dajani
Concerns ‘What we don’t want to happen is another tier of pharmacy. If they’re not speaking to anybody else they could end up operating in a vacuum.’ John D’Arcy