Engaging a Practice Pharmacist

Quite incredibly a GP asked me about employing a practice pharmacist. He had heard a lot of rumours and a practice nearby had just appointed one. The starting point was the question why. But an answer about additional skillmix, improved quality of patient care had little real impact so we started a different discussion:

  • Your practice gets 100s of letters and communications every day – perhaps 25 of these include additions or changes in medicines – do you put them on your clinical system yourself and do you ever feel that you need to check something? Do you have the time?
  • You issue 200 repeat prescriptions a week – each – do you ever wonder if they are OK, need reviewing or checking – is your system robust and reliable?
  • Do you ever spend time talking to patients about their medicines, sorting our queries, drug shortages or completing more structured medication reviews?
  • Do you have care homes with residents that might benefit from a medication review – some ‘deprescribing’ or setting up medicines action plans to avoid admissions?
  • Are you up to date with shared care arrangements and feel certain that high risk medicines are properly managed?
  • How many of your consultations are with patients with acute common conditions that could be managed by a pharmacist within the practice?
  • Do you have to complete audits/reviews as part of your contract or additional services?
  • Do you need help to achieve full QoF points or perhaps LES or DES payments? Are you missing out on potential income?
  • Are you fed up with being roped in to give flu or other vaccinations when it is busy?
  • Are you worried that the CQC are going to ask difficult questions about medicines management and expect to see evidence of delivery?
  • Are there chronic disease areas where the addition of a clinical pharmacist to the current team, might mean that they can manage a larger percentage of patients without referral to you? What value would an additional independent prescriber bring to the service?
  • Are you just tired of being in the practice late, unable to recruit GP help, can’t find practice nurses and not enough time to spend with patients that need your expertise. Is it just not fun anymore?

If you have answered yes at least 10 times, then convert the above into a job description. Add some skills and knowledge, perhaps a few competencies – working in a team, but independent thinking – you know the sort of stuff. Think of a salary scale – perhaps band 7 or perhaps 8a if they have areas of specialism or are an independent prescriber. Write an advert and give it to your CCG – put it in a journal or on line. Ask the head of medicines management to help select and interview or another practice pharmacist and just get on with it. Open the interview with ‘what do you think you can contribute to my practice’ and you are away.

The only remaining question – is one going to be enough?

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Partnership in immunisation

A GP and a community pharmacist were sitting in the coffee shop – well sitting in the bar would sound like the start to a joke.

The GP says – “you know I hate flu immunisation. We have so many to do the practice is absolutely full; they are expanding the numbers all the time, then moan when we don’t surpass the targets. We have to put on extra clinics and are even thinking about opening at the weekend – but with all the overheads we are hardly likely to break even”.

The Pharmacist says – “Ha – I hate Saturday afternoon and Sunday. We are open and you are closed, it is hardly worth it for me, but it is part of my contract”.

A lightbulb moment!

“How about running the additional flu clinic in the pharmacy. You book patients in on a Saturday and Sunday. Double book them and your nurse and the duty pharmacist can alternate patients so we both make some money”.

“Hmm”, smiled the GP, “and I wouldn’t need to open up”.

“No, and while the patients are waiting they might get some advice on other common conditions or even buy something”.

“Sounds like a good arrangement to me”, Agreed the GP. However, last year one of the practice nurses had an accident and went sick, if it happens again could you help me out?”

“OK – I have three pharmacists that work for me, I am sure I can arrange for one to do some of your clinics if you cover their costs”.

 

Now why doesn’t it work like this everywhere?

Health vs Illness

I had an interesting discussion with a GP. How do we differentiate General Practice and Community Pharmacy in a patient’s mind? It is not easy when the services delivered in community pharmacy are variable. The politics are also variable – we are told to visit community pharmacy for common ailments and then we are warned about cancer and told to see a GP.

So I said – it all depends on whether you are healthy or ill. If you are essentially healthy you should visit the pharmacy and if you are ill, you visit the GP. In the backroom you join them together and then you create a compatible contract with elements of profit share and joined records.

So when do you visit the pharmacy and what services should they provide. Think about it – when you are essentially healthy you go to the pharmacy. This might mean:

  • Common minor conditions
  • Routine immunisation
  • Travel health
  • Obesity, smoking and exercise management
  • Emergency hormonal contraceptives and general contraceptive services
  • Child health

‘Hold on a minute – all immunisations’ – yes these patients are not ill and the whole point is to tell patient to only go to their GPs when they are ill – really ill and the GP practice will look after them. When you are not ill then you go elsewhere – to the pharmacy.

You aren’t ill when you need a contraceptive – you aren’t ill when you go on holiday and children aren’t ill.

‘But how would you deliver this’. Community pharmacy can employ nurses if that is appropriate or use pharmacists. We are well used to this mix of staff delivering good care. It would just need the contracts to force working together with some cross management of resource.

‘What do you mean – cross management of resource?’ The community pharmacy may contract nurse support from you and you may contract pharmacist support from them. When you both have access to the medical records, it matters less where you practice and operate the services.

‘But will we lose money?’ That is the whole point of shared contracts – so the delivery becomes a shared responsibility and you are jointly paid for delivering outcomes. It is not beyond us to develop something like this is it?

The whole point is that we have to simplify the message to the population in a manner that they can understand. If you are ill go to the GP, if you are generally well then see the pharmacist.

The community pharmacy is like a branch surgery

I thought he was joking, but it was some poker face. You are joking – right?

“No seriously, we now have an increased relationship with two of our local community pharmacies and it is just like having branch surgeries. They have CCG funded minor ailment schemes and we work closely with them to develop this to the maximum”.

So how did this all start?

“The CCG let us know that they had commissioned this service and we invited the two closest pharmacists around for coffee after surgery and they had closed to understand what this actually means”.

“So the community pharmacists delivered a short lunchtime session to all practice staff on what they felt competent to manage. The receptionists have a list and a leaflet and they actively divert patients to the local pharmacies.”

How does this work for the GPs?

“When patients visit the surgery with listed conditions we try to ask them if they have been to the pharmacy. This was a little tricky at first, but it is now fairly routine. Patients now ask us if they could have seen the pharmacist”

Have you had any issues?

“Not really, but we do have a monthly catch up session. The pharmacists come over at lunch time. They talk about some cases that they treated or referred and we explained what we would have done.”

Has this led to any improvement?

“Well the pharmacists now seem more confident – they have developed some additional diagnostic skills and will deal with more conditions”.

And the patient viewpoint?

“At first some were surprised, but it is much quicker to get to see the pharmacist than the GP and they get similar advice. Of course some prefer to come to us, but a lot are happy to see the Pharmacist”

Have there been any other additional advantages?

“We are more aware of the other commissioned services that the pharmacies deliver and we actively refer to their services. We better understand MUR and NMS and try to make these services work for both of us. We now refer all of our patients to them for smoking cessation as it is uneconomical for us to do it. The improved communication has allowed us to sort out prescribing issues quickly and we take advantage of the emergency supply service.”

And what are the plans going forward?

“The pharmacies both support inhaler technique monitoring in all patients with asthma and COPD. We have been working together to identify high risk or poorly controlled patients, using a small amount of money from an innovation fund. This has been going particularly well and we have reduced unplanned admissions and improved quality of life for our patients. The Pharmacists have a ‘hotline’ to us when they feel that a patient has problems that need urgent attention. And we have even used skype and facetime to hold a consultation with our patients in the pharmacy. We would like to expand this to other clinical areas such as dyspepsia and IBS, before dealing with hypertension and even diabetes.”

Why don’t other GPs share your view?

“We are very busy, but we felt that we had to look for other ways of dealing with our workload. We invest one hour a month for a chat over tea and sandwiches and it frees up at least 5 times this number of appointments in our practice. We have developed great relationships with our local pharmacists and it works. I am sure that there are many that do understand the benefits of working with the local pharmacists, but it needs a little bit of effort.”

In summary, working closely with your local community pharmacists has led to benefits for both sides.

Message to General Practice – come and get me!

This is a simple message from us clinical pharmacists to all you GPs out there.

When you are looking to make a change in your practice, when a partner leaves, a nurse retires or you don’t feel that you can afford the current locum or salaried GP rates – come and talk to me.

I am a pharmacist – I have additional clinical qualifications to pharmacy and have spent most of my life working with patients, their conditions and their medicines. I am logical and organised – almost to a fault – and like you am used to working within a very busy team where we all throw our efforts together. OK – I may ‘think’ I know more than you about medicines, but you are streets ahead of me on other areas. I may need lots of help, but it may all be mutually beneficial.

If you would like me to – I can join your practice as an employee and do the following:

  • Manage your repeat prescribing system and deal with all the queries (implement electronic prescription management)
  • Handle all of the clinic letters and discharge letters
  • Review your patients who are on complex medicines
  • Help deliver your QoF, LES and DES services
  • Ensure that the whole practice knows the systems that are in place and about new medicines and guidelines etc
  • Work with the CQC inspectors who are asking about medicines management and ensure your practice passes this aspect of their inspection

To me, this is all quite simple. I know plenty of fairly young pharmacists who are already doing this. However, I could also do the following:

  • See some of your patients with common conditions who present at your practice, offering routine and emergency appointments – a bit like a nurse practitioner
  • Work with a specified GP and your practice nurse to manage long term condition patients. I have done hypertension, cardiovascular risk, respiratory (asthma and COPD) and diabetes clinics before, a bit of complex pain management, ostomy and wound care (I learnt pressure bandaging at St Georges’ in the day)
  • Run your anticoagulant service and other near patient testing services – I even do dopplers and recommend on post DVT management
  • I will even roll my sleeves up and do some vaccination clinics

Where I am yet to train as an independent prescriber, you can help me with this, although many of my colleagues are already independent prescribers. I know my limitations, accept my responsibilities and can work effectively with colleagues in a team.

If you would like to talk to a pharmacist already working in a GP practice or to the GPs that have employed them – please let me know – there are some cracking good examples around – one that might win an HSJ award next week!

If, unfortunately I am not able to join you, it is estimated that several thousand of my pharmacist colleagues will be available over the next few years – strictly on a first come first served basis.

On the other hand – you could always work harder or close

Urgent and Emergency Care

I was invited to speak at the future of urgent and emergency care services. It is unusual for a pharmacist to be invited to this sort of event – well I wasn’t directly, but Dr Michael Dixon felt that I would answer the brief about pharmacy to compliment his opening. As expected, there wasn’t a single pharmacist in the audience. The first batch of speakers talked exclusively about new ways of working in A&E and urgent care centres – somehow I didn’t expect anyone to mention that pharmacists are employed in these services, as well as out of hours and General Practice to provide care for patients with common acute conditions, but as usual community pharmacy was not mentioned.

Feathers slightly ruffled from the start. I had to explain that there was slightly more than General Practice within Primary Care – General Practice is only one of the four independent contractor contracts within primary care – and they all provide urgent care for patients. I had to explain that within NHS England’s report they clearly suggested that a shift all the way down the line was needed with increased focus on self-care and community pharmacy to relieve the increasing pressures up stream. And, with more than 438million healthcare interventions in community pharmacy (2008/9 data) – this was more than any other profession added together. You do realise that the community pharmacy estate is huge – more premises and open longer than GPs and often more convenient for patients.

I mentioned data around the symptom checker – just to remind people that most members of the public who used the symptom checker were young and female. And that 44% still went for a consultation. There is a hint there, that putting symptom checkers in unsupported environments, like libraries might just increase demand on general practice and other services.

I offered a solution of putting NHS Choices symptom checker into community pharmacy, backed up with access to an assistant or technician that can support navigation and a pharmacist should further explanation or an intervention be necessary. Link this to the Healthy Living Pharmacy initiative with qualified health trainers and you could really start to change behaviour and attitudes towards better health.

I talked about minor ailment services – renaming them ‘common acute condition services’ and despite over 1,000 pharmacies being open 100 hours a week and many more open 80 hours a week, this service was commissioned in only 10% of pharmacies. There was service specification variability and access to medicines was generally poor. Access to medical records is still zilch, although access to the summary care record is on the horizon and will help in the future. As a side comment, if I had £1 for every patient that had been passed over to the GP for a prescription, I would have retired long ago! It is also sad that a pharmacist at 21.55 in the evening can’t book a patient into the GP next day or skype call to an out of hour’s service for support – so you can guess where those patients go.

I mentioned that the first minor injury training program, specifically for pharmacists was to be delivered this summer. Not requested by the NHS, I might add, but by pharmacists who, no doubt, will pay for their own training to deliver a higher level of service to their patients.

I was openly critical of the lack of working together in these services and suggested that it should be a basic requirement that GPs and Community Pharmacists work together to develop these services to the level that they need to be. In my opinion this is a serious flaw and limits the success of services. If the GP, Practice Nurse or receptionist simple enquired – “what did the pharmacist suggest” to patients with common acute conditions, perhaps we could turn this tanker around.

I questioned the use of NHS 111 where I am still not sure offers community pharmacy as a disposition. And the very few CCGs that underwrite the supply of medicines from a pharmacy in an emergency situation. There is no more of a heartsink moment in A&E when a patient turns up and says – “I am on holiday and I’ve forgotten my medicines and I’ll die without them”.

Those professions at the ‘bulk’ end of the scale –  General Practice, Community Pharmacy, Optometrists and Dentists must work together to create capacity and deliver more effective and more integrated care. We must share the load, and support more effective self-care to give those clever people at the top end of the system a little more space and time.

Polypharmacy and medicines optimisation

It would seem that polypharmacy is on the increase and that is no surprise to me. I am occasionally asked to review medication as part of a team providing direct care and I often hold my head in my hands.

We may call this process medicines optimisation, but it is half a job and the medicines optimisation specialist pharmacist within General Practice are making a mistake when they review individual patients and make recommendations about their medicines. This does not change prescribing behaviours and we should consider a new approach.

Having reviewed some elderly patients on multiple medication the key question is not what we should do now – that is usually simple – but how and why have we arrived here. So with a group of prescribers I have asked those questions using case examples in a non-judgemental way.

The discussion is always interesting and often I have to agree that it might have seemed a good idea at the time; often it fitted with a guideline or a protocol. But the discussion generates further questions:

  • So what were you hoping to achieve with that prescription (what was the goal)?
  • Was it something that was important for the patient? Would it make a difference to their quality of life?
  • What were the chances of that medicine achieving that goal, bearing in mind the patient’s condition and the evidence supporting the medicine in that patient?
  • Was there an intention to review and what criteria were you going to use to define success?
  • Was there any other way of achieving the desired result without medicines?
  • What support was necessary as an adjunct to the medicine to achieve the desired goal?
  • What was the strategy if that medicine did not achieve the desired effect and had you explained that to the patient/carer?

The discussion was peppered with a variety of phrases including:

  • That medicine is not actually licenced for that indication
  • There is little evidence of benefit in this age group
  • The medicine is unlikely to achieve that goal

There were many obvious comments:

  • no medicine is indicated for loneliness (still waiting for social prescriptions)?
  • A pain killer is only likely to reduce the pain by 50% so how does the patient manage the remainder?
  • What are you hoping to achieve with that medicine (often a statin or aspirin) in an 85 year old?
  • What potential expected side effects are likely to be detrimental (falls, hypos or confusion etc)?

At the end of the session I am happy with the question – should we stop this medicine – and even happier with the recognition – perhaps we shouldn’t have started it in the first place. Sometimes the questions are much more exciting – how are we going to manage a group of patients with these problems in the future – and we might look to involve local voluntary, charitable and housing services along with community pharmacy in solutions.

So if you want to effect polypharmacy and optimise medicines, don’t think about what you do now, but reflect on how you have got here and most importantly how you avoid this situation again.

The death of independent contractor status

I was both surprised and pleased that Clare Gerada, Chair of the RCGP was brave enough to call for a re-evaluation of the current independent contractor status model. She was right to do so and her profession would be wise to listen and think about it before jumping to say no.

I was a mere child when I locumed for a community pharmacy owned by Alan Lloyd. He owned a couple, but at that time most community pharmacies were owned and run by individuals. Pharmacy was a ‘good business’ and Alan Lloyd moved from a single pharmacy in Polesworth to own over 900 when Celesio acquired the largest pharmaceutical wholesaler in the UK and the Lloyds pharmacy group over a couple of years and are now own over 1,600 pharmacies in the UK. Even so they are dwarfed by Alliance Boots who own over 3,000 pharmacies around the world and revenue at about a quarter of the NHS.

I say all this because ‘good business’ can so easily become ‘big business’. The world for GPs is changing. General Practice has always been ‘good business’. It is becoming harder to attract new partners who either wish to join a practice or have the funds to do so. ‘Big business’ is slowly creeping in and soon you will face some of the same issues that community pharmacy face.

For community pharmacy, most of the front line pharmacists are salaried employees. Approximately two thirds are in large organisations with at least 6 pharmacies and with a pre-defined career structure in place. There are only an estimated 5% of pharmacies which are owner managed.

The problems with this position are too many to mention in a single blog, but here are a few:

  • The contract negotiation power lies within the owners and not the pharmacists
  • The voice is fragmented and diluted with several ‘representative’ bodies
  • Business has a shareholder requirement for profit which chases revenue and reduces overheads. Pharmacists are overheads and feel the effects of increasing workload and reducing rates.
  • Co-operation between independents is impressive, but it can be difficult to encourage multiples to operate independently to suite local needs and in co-operation with neighbours
  • Multiples have the capacity to run their own health campaigns
  • Career structure encourages movement between pharmacies and does not incentivise retention in a single pharmacy

So let’s listen to Clare. I want community pharmacies and GP practices with both stability and close working relationships. I want to see the same GPs and the same pharmacists, working together and sharing expertise and running more local services in association with social care and the rest of the local authority. How can we solve the problems that our communities face if we cannot work together as a community?

I say well done Clare! I know the model that I want to see and I am not sure that the independent contractor status facilitates that move. The GP contract is archaic, based on a poorly defined capitation, but you do still retain mostly independent practices. The community pharmacy contract is archaic, derived to reduce the drugs bill and most of the pharmacies are within private limited companies. Wouldn’t it be nice to see us move together under a new contract that respects the GP and the Pharmacist as individuals, but encourages us to work together in groups serving communities?

It is not about scrapping the independent contractor status, but about moving it to something a little more modern and appropriate for the day and the current problems. Over to you Maureen?

When is a medicine not a medicine

I know it sounds like the beginning of a joke like:

When is a door not a door – when it’s ajar!

 

This is far from a joke and a very serious question. A medicine, after all, is just a chemical in a pill.

But a medicine is far more than a medicine when it is part of a ‘treatment’. Let’s start at the beginning – it all starts with a human being. You see I don’t want to call them patients or clients or individuals – they are just ‘somebody’ at the beginning – ‘somebody with a problem’.

Showing you care  – as a healthcare professional I care – it says so in the title – so what does that mean? It suggests that I have time and I am interested. There is a saying:

“They don’t care what you know – until they know that you care”

So whether you WWHAM or you RAT it doesn’t matter unless you demonstrate that you care.

Understanding the issue – many people come in ask a question without really stating the issue. I have talked about that re insomnia where people say they can’t get to sleep, but their real problem is that they feel bad the next day. It is a real pity that some would knee jerk to prescribe a benzodiazepine or z drug and make the next day feel worse! So keep asking the question until the person describes their real problem.

Setting goals – this is very important. The goal setting is necessary for adjusting expectation. Someone with chronic pain is unlikely to improve by more than 2 points on a visual analogue scale – it’s not pain free – but it may allow some relief at some time of the day. And for targeting treatment when you decide which symptom is the one that needs action. You may not be able to target everything in one go – so start with the symptom that causes most problem, review and set new goals.

Creating texture – there are usually things that you can do – lifestyle changes – and coping strategies – psychological support – that constitutes the rest of the treatment package. These are the things that may allow the person to take less medicine in due course or even stop. They may allow the medicine to continue to work and arrest some of the factors leading to the symptom expression.

You have always heard the conversation – if you weren’t so fat your knee wouldn’t hurt so much – yes and if my knee didn’t hurt I would move about a bit more and lose weight. Sometimes a short term treatment might create a window of opportunity to change lifestyle enough to get on a path of recovery.

Selecting the medicine – There are many reasons to select specific medicines. Obviously I am going to base this on evidence of safety, efficacy and patient factors/experience. These are the most important, but I will also consider cost. Seldom have I been asked by a patient to treat something that is clearly an end point in a trial. People with diabetes don’t ask for something to bring down their HbA1c. This does require a higher level of investigation and interpretation to find the data that I really want.

Delivering the treatment – so do it. Deliver the treatment package including, if appropriate a medicine. Review what you are doing and make sure it is patient centred and with safety in mind. Check again that the person is engaged and still wants to go ahead. Make sure that there are not barriers that might get in the way of compliance and send them on their way.

Following up – check up on the person and on their progress in line with the expected patient experience. There are times when they will question the treatment and their progress and the future – just be there. But the most important thing here is to learn. My biggest problem here is that I don’t have those symptoms and I haven’t taken the treatment. I have read a book and a paper, but do please remember:

“Talking to people is the only real way to hear – caring is the only way to learn”

It’s all about skill mix

I have heard this term four times in the last week as I nodded sagely to their comments. It was strange because it was doctors talking about pharmacists. So perhaps the message is getting out? Here are the examples:

Talking about the provision of out of hours.

  • we were a seaside town and many of the patients attending out of hours had medication related problems and many were away from home and had minor problems
  • and it was just difficult and expensive to get enough regular doctors

So we have a pharmacist on duty every evening who can deal with those problems. That’s right we have a nurse, a pharmacist and a doctor and patients are triaged appropriately. We are working on the next stage where we triage some patients back to community pharmacy before they attend our service.

Talking about managing long term conditions.

  • We had a significant number of patients who did not hit reasonable and, in our opinion achievable, hypertension targets despite the best efforts of the nurse and GP
  • We already had access to a pharmacist who run our whole repeat prescribing system, ensuring patient safety

So all patients that were considered uncontrolled we referred to the pharmacist. She took part in a recent study which won the Pharmaceutical Care Award in 2013 where 58% of uncontrolled patients hit NICE targets. It is obvious to us that the issue was either medicine selection or compliance. We achieved great success and avoided many secondary care referrals

Talking about ‘Pharmacy First’ schemes

  • We used significant numbers of acute and routine appointments, seeing patients that our local community pharmacist could have dealt with

I know that a lot of patients come to see me when they could have seen the community pharmacist. So the PCT introduced a ‘minor ailment’ scheme. There was quite a lot of publicity and we noticed the difference. We work very closely with our local community pharmacist and support him in dealing with some patients. Their pharmacy is literally a stone’s throw away and our patients have to pass his door to come to the practice.

We have started asking the question ‘what did the pharmacist say’ and I think that the message is getting through. We have fewer minor ailments in our clinics and better access for patients with long term conditions.

Fighting flu

  • We missed our target for the under 65s
  • Despite sending out letters and pestering people we still missed our targets.
  • The winter flu campaign already causes significant disruption to the practice and we have significantly more to do this year

It wasn’t as if we hadn’t tried. We wrote letters, made calls, but many of the patients under 65 did not respond. We did ask a few why and it was a whole mixture of things. Well last year we reached out to our community pharmacist who was being commissioned by the PCT. Every patient under 65, picking up their medicines was asked about flu. They were either given the vaccine on the spot or booked into our clinic. We had the names, dates of birth and batch number of immunised patients every day. The community pharmacist also focussed on healthcare and social care workers and helped with the residential homes.

OK we missed our targets again, but only by a whisker. This year I feel confident that we will hit them comfortably.

 

So, with resources tight, goals and targets being stretched, the need to do more for no more money – it’s all about skill mix – ensuring that the right people do the most appropriate jobs in a joined up manner.