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.

Travel Health

This was an interesting conversation with a GP.

I overheard the receptionist say to a patient “Why don’t you go to Superdrug?” Well this is not something you often hear in a GP practice. And the practice nurse jumped in with ‘ask for Jackie – she will sort you out’. This was followed by a supportive smile and a nod of agreement by both members of staff.

On the way out a patient in the waiting room joined in with ‘they are very good, I always go there’. What is going on? This is hardly the way to run general practice so it is important for everyone to be suitably quizzed!

The patient wanted advice about travelling to the Far East on holiday and rather than booking the patient into the travel health clinic, they were referring the patient to a community pharmacy. They say that this is routine now and the patients are OK with it. In fact they seem to support it. So I had to go and investigate….

I have to say that I had to push my way past shoppers and isles of cosmetics and sundries, but I arrived adjacent to the pharmacy section to a sign that said ‘Travel Health Service’. It looked professional and there were leaflets and a large map on the wall.

I asked for Jackie and was met by a nurse – ‘I know you’  – I suddenly blurted out. Yes she was an ex-practice nurse that was now working for Superdrug – who would have guessed!

Her office was small, but professional and she explained that she worked with the pharmacist to deliver a full travel service including yellow fever and rabies. They had expanded and now there were three part time nurses that run the service. They will prescribe/supply malaria treatments and administer vaccines and offer travel health advice. There was a whole section of stuff that I might need from flight socks, through mosquito repellents to nets and everything you could think of all in one place.

I left both pleasantly surprised and a little annoyed. Why didn’t I know about this service and it was probably better than the one offered in the practice.

The practice nurse was happy to admit that she saw less patients now for travel advice – “they have a better set up and can offer more than we can – it is not as if I haven’t got other things to do”. Do you still offer a travel health service – ‘yes of course we do – there are patients who want to see us – but many seem happy with the community pharmacy and there are a few that we have to refer there anyway’.

So what a learning exercise that was. An hour a week of senior practice nurse time saved and the patients actually get a better service.

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

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?

Community Pharmacy co-operatives in Primary Care

Community Pharmacies must start to think in a co-operative way. This is the way to encourage change. Change that delivers better outcomes for the local communities.

Primary care is mainly built with independent contractors. In fact four groups of independent contractors operate within this arena. You could mix in here a community services provider, a mental health provider and a social care provider. And add a little police and ambulance and fire services, some housing and education with a whole host more. Well that is what makes up community based public services. The contracts are all set up individually which creates isolation, competitive behaviour and gaps between services for people to fall between.

It has to stop! We have to start to think in a more joined up manner which starts with the community at the heart and builds the services around in a joined up manner.

I am seeing GP practices forming co-operatives. One in Brent provides services for approximately 80,000 people. The co-operative are able to provide a greater range of services, sharing both management and clinical skills and experience across the group. The sharing is important for them to all improve to a level and move forward consistently providing a quality service to their community.

As a guess there would be 10 community pharmacies that are within the boundaries of the co-operative. A further guess would say 5 independent or small chains and 5 from the multiples. I could add 6 dentists and a further 6 optometrists, but that would add a further layer of complication for today.

Would the 10 community pharmacies form a parallel co-operative and create a memorandum of understanding? Would they get around the table as a ‘team’? And would they discuss the needs of the local community with the local community to work out how they could better work together as a group and as an important part of a larger initiative? And would companies change their ways of working to support this?

I was going to focus on the multiples, but I suspect that the independents won’t find this easy either. It requires some fundamental changes in the way that Pharmacies are run.

  • Co-operatives must form a general working structure that allows them to meet with and work with other local service providers
  • Pharmacists, usually managers rather than owners, must be empowered and supported to negotiate local working arrangements and service development.
  • Pharmacists must be supported to develop local services within the joint co-operatives either in tandem with or instead of national company driven services
  • Companies must find ways of supporting and incentivising stability within a single location

Members of that community will begin to see that they have not 10 access points for healthcare, but 20 and services that might be offered by a few can now be offered by all. With co-ordination and information sharing it might just look seamless. MURs and common complaint services can link across practices and pharmacists can join in late night and out of hours provision. A wider range of public health services would be more efficient if fully linked up with GP practices.

This might seem a big hurdle, but to get 10 GP practices and 10 community pharmacies working closely together in a single community will be a great start and an example to encourage other providers to join together.

Jeremy Hunt’s Folly

Soon we will have GP surgeries open from 8 in the morning to 8 in the evening seven days a week. And we are all supposed to think that this is the solution to all the problems in the NHS. Am I the only one that thinks this is folly – election-mongering – playing to the audience?

GPs work very hard at the moment. The good old days of 5 surgeries a week, a day off and two rounds of golf are a distant memory, replaced by exhaustion and burn out. Already the requirement for GPs to be commissioners is taking its toll with more resignations from board positions. Our delivery of services for long term conditions need to be revamped as the outcomes could be better and it is difficult to get an urgent appointment during the day. And we are still failing to link health and social care properly and many GPs feel that they are becoming social workers!

We are also expected to believe that it is both necessary and desirable for the practice in the middle of a residential area to open 7 days a week with the traffic and commotion that will be caused. And what about current lease arrangements – will the landlord change the conditions of the lease – and will the council approve it. Has Jeremy been advised on the feasibility of achieving this?

Do we want to go to a GP surgery at 7.30 on a Sunday evening? Is this late and weekend opening what is necessary to care for the vulnerable and the elderly in our communities?

Strangely, however, some practices manage very well. I can get an appointment to see the doctor of my choice – as long as I can wait a few days. I can get a same day appointment – as long as I am happy to see any GP or the nurse practitioner. I can book on line, manage my prescriptions on line and speak to a GP/nurse at certain times of the day. There is a sharing of resources between practices so I can get to see someone who knows about my conditions.  If it is late or the weekend I can visit the community pharmacy which already opens from 8 to 10 and offers a ‘Pharmacy First scheme. If it is a problem with my eyes or my teeth then there are emergency services in place for these. Actually the local GPs, the community pharmacies, the optometrists and the dentists are OK. I can’t comment on the link between health and social care and I can’t understand what all localities don’t work like this.

What do we know?

  • We know that there are barely enough GPs to go around, their locum rates are drifting towards £100 an hour and there is at least a 6 year lead time to create more.
  • We know that there are 57,000,000 GP appointments for common conditions that could be managed within community pharmacy.
  • We know that if we create more GP appointments, they will be filled with a variety of people, some who could have gone during standard times and some with common conditions that could have been treated elsewhere.
  • So what other options have been considered? I don’t know. I haven’t seen a report into the problem and an option appraisal. It has been driven before the Royal Pharmaceutical Society Commission on models of care has been published. It is all a bit of a rush – don’t you think – but it does make good headlines before a Party Conference?

So what is the real problem?

  • A&E is full. Actually it is not through an increase in ‘blue-light’ cases – these have hardly changed. It is full of the walking wounded and a third of these have common conditions that could be managed within a community pharmacy.
  • GPs are overrun. They are trying to manage an aging population with more long term conditions and meet targets such as QoF within an out-dated capitation based contract.
  • Walk in centred haven’t worked – because they are a sticking plaster to create headroom in a system.
  • NHS Direct demonstrated the requirement for access and information. NHS 111 has not been integrated with other front-end providers of healthcare – community pharmacy is usually not included.
  • Community pharmacy has not been engaged. They too are working within an out-dated dispensing focussed contract. Only 12% of the eleven thousand plus community pharmacies in England provide a ‘pharmacy first’ or a minor ailment scheme and some of those have been restricted when they needed to be expanded.
  • We haven’t thought through the role of social care and communities in this at all. Perhaps the Health and Social Care Commission run by the Kings Fund will redraw the boundaries between health and social care in the field of acute conditions to engage healthcare through a different process compared to calling an ambulance.
  • The population has not been engaged and offered appropriate solutions to their needs. The only constant feature of the system is A&E so you can’t be surprised when people go there.

The long term solution

  • Support General Practice to develop, working together to raise the standards of care across federations or consortia.
  • Redesign ‘Pharmacy First’ schemes to provide a real alternative to General Practice and A&E for people with acute presentations of common conditions.
  • Integrate ‘Pharmacy First’ scheme providers with NHS 111 so people can talk to a pharmacist on the phone as a first port of call.
  • Integrate ‘Pharmacy First’ schemes with GP practices and current out of hours providers to triage all patients with common conditions and offer a community pharmacy based solution.
  • Fix the limited supply of medicines through community pharmacy. If it’s free on prescription, then it should be free at a pharmacy. Allow community pharmacists better access to PGDs or develop Independent Community Pharmacy Prescriber (limited formulary) status.
  • Build the links so a community pharmacist can book a patient in with a GP on the next available appointment time and support teleconsultation, particularly with out of hours providers.
  • Communicate this to the public, nationally and locally. Let the people know where to go and for what condition.

Will it work?

  • I have been very impressed talking to Caroline Kirby on how their federation of GP practices share skills and expertise and deliver great care to their population of approximately 80,000. The next opportunity will be to join up community pharmacy and other out of hours and social care providers with them. I am sure that there are other great examples of working together across primary care providers and plenty of potential.
  • We know that ‘Pharmacy First’ schemes such as in Croydon, Bury, Yorkshire, Birmingham and many others are working well providing alternative sources of healthcare, reducing demand in general practice and A&E.
  • Many pharmacies are open long hours – nearly a thousand are open for 100 hours every week and many more are open 80+ hours already.
  • The pharmacy profession wants to be included within ‘Pharmacy First’ schemes and there are plenty of well-qualified pharmacists around – no shortages here.

In my past I worked as a business manager dealing with waiting lists. We provided additional capacity and the lists fell beautifully from 30+ weeks to below 6 weeks wait only to find that demand rose and the lists grew again. Throwing money at capacity without dealing with demand just doesn’t work.

So we are now doing the same thing and expecting a different result. The government must be insane and I must be Einstein!

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”