Clinical pharmacists in general practice - IntraHealth

12 February 2018

Background

IntraHealth has been successful in its application, for phase 1 of the pilot, to NHS England and the NHS Leadership Academy for four pilot sites to be part of the national programme to introduce clinical pharmacists in GP multi-disciplinary teams as an integral part of the GP workforce 10-point plan.

The practices in the pilot are:

  • Bilston Urban Village Medical Centre
  • Sai Medical Practice
  • Pennfields Medical Centre
  • Kingshurst Medical Practice

The company’s vision is ‘a community where every patient matters and their personal health needs are fulfilled by caring, dedicated teams and a leading innovative provider of health services’. 

To fully show case the successes of the pilot, the case study is split into two sections.

The first section identifies the input from PCC to work with the four sites to observe how the practices have worked to embed clinical pharmacists into the teams.

The second section has been developed by Sheetal Kotecha, Clinical Pharmacist based at Kingshurst Medical Practice, which shows the improvements made to primary care by the clinical pharmacists’ working across the four pilot sites. The improvements have focused on:

  • Reducing GP workload
  • Improving patient satisfaction
  • Improving patient safety

Section one:  PCC facilitative support

Primary Care Commissioning (PCC) was commissioned to facilitate development sessions with practices participating in the programme. Barbara Dingley, Associate Director with PCC provided facilitative support throughout the period of support.

The first PCC session with the practices in the pilot discussed the programme of support that was available. It was agreed that sessions would be held with each of the individual practices, as well as with the clinical pharmacists, to determine the current status of readiness for implementing these new posts into each practice.

The meetings held in each practice which focussed on discussions about how much each team knew about the programme and the benefits of having a clinical pharmacist working in the practices, managing patient expectations and overcoming resistance to see the clinical pharmacists.

At the first meeting with the clinical pharmacists, Barbara used the NHS sustainability model for the clinical pharmacists to self-assess each practice, which identified strengths, barriers and planning required to ensure the implementation of the new posts was sustainable against three areas: process, staff and organisation.

Outcomes

Individual practice meetings

Meetings were held with staff at the four sites, the sessions were informal and engaging and offered the opportunity for open discussion and review of achievements to date. Some of the key findings from the meetings with each of the four practices was as follows:

  • Reception staff understood the purpose of the new posts, recognised the importance of the clinical pharmacists role in the practice and were able to discuss these benefits to patients. Some benefits identified included:

o   More appointments available for patients, so increased access

o   The clinical pharmacists were able to spend time with the reception staff explaining medication queries

o   Taking pressure off the GPs

o   Clinical pharmacists are able to deal with repeat prescription requests quickly

o   Clinical pharmacists have more time to review hospital letters and review medication if required

  • The individual clinical pharmacist(s) were integrated into the team at each of the practices
  • The reception staff had spent time talking to patients about the benefits of booking appointments with clinical pharmacists, encouraging and offering re-assurances. some approaches adopted included:

o   Quicker to get an appointment with the clinical pharmacist rather than having to wait to see a GP

o   Assuring that the clinical pharmacist can prescribe and refer to other specialists

o   Best advice about current medication being taken

o   Able to see a GP if they feel it necessary, which rarely happens if at all

  • There was concern from clinical pharmacists that some patients did not understand that they were a pharmacist and not a GP. However, it was made very clear when the appointment was made who the patient was seeing. The clinical pharmacists also explained who they were to patients at the beginning of the consultation.
  • Staff used the approach adopted when nurse practitioners were first introduced to the practice.

Some changes suggested to embed these roles further by the practice teams were:

  • Provide more patient information – leaflets in the waiting area, on the notice board in the waiting area about the people working in the practice
  • Learn from the approach taken when the advanced nurse practitioners were first introduced to general practice
  • Discuss with patient participation group and ask them to promote the clinical pharmacists

Feedback from members of the practice team included:

Clinical pharmacists

  • “As a general group of pharmacists, there is a lot of variety within the team in terms of our professional backgrounds, which I believe has added to the strength of the overall impact we have been able to provide. 

On a personal level, I feel that the importance of quality improvement indicators that we have provided has been demonstrated and acknowledged, not only within IntraHealth, but also wider within the CCG.  One of my tasks in year end 2017 was to review patients with inappropriate polypharmacy at my practice, and address concerns raised. 

We were tasked by the CCG to review 1% of the practice population, this equated to approximately 70 patients over the course of the year.  I decided to put a template together to address some of the quality indicators, but also to ensure that we were all working to the same level, and set a benchmark. 

On completion of the reviews, an audit was carried out by the CCG Prescribing Support Pharmacist on 10% of that patients reviewed, and showed a staggering 42 interventions were made, 3 of which would have prevented hospital admission.  The results, extrapolated back to the whole cohort, showed annual savings of circa £1,600.*  If these figures were to be further extrapolated across the 4 sites within the pilot, the improvements made to patient care, as well as the cost savings, can soon gather momentum.

The above is a good demonstration of the value we are adding to patient care as well saving money for the NHS.  Through this exercise we have also gained recognition from the CCG.”  Sheetal Kotecha - Clinical Pharmacist, Kingshurst Medical Centre

* the above data was collected and collated by the practice Prescribing Support Pharmacist on behalf of Solihull CCG and is used with permission from the CCG

Practice manager

Really pleased, everything on track

Reception staff

  • Generally, patients are more than happy to see the clinical pharmacists
  • The receptionists could not do their job without the clinical pharmacists and wonder how they managed without them – “please don’t take them off us” and “we think they’re brilliant”
  • The older generation quite often prefer to see a clinical pharmacist because they can have a longer appointment
  • Appointments with the clinical pharmacists are filled first and in many cases patients will now ask to see the clinical pharmacist in the first instance

GP

  • “The clinical pharmacists program has been a revelation. It has completely changed the way I view my working week and has freed up more of my time so I can focus on complex patients, practice management and more importantly family time. I was struggling under the increasing burden of work in General Practice and taking work home with me on evening and weekends… thankfully that does not happen anymore.”  Kamran Ahmed – Local Medical Director for IntraHealth

Section two:  Improvements made to Primary Care by Clinical Pharmacists

IntraHealth identified the benefits of employing clinical pharmacists to work in practice over 15 years ago and have been providing medicines optimisation services to practices since 1999.  The company could see the benefits that pharmacists have brought to patient care and is the reason they applied to join the national pilot programme and maximise on the additional support that clinical pharmacists can bring.

Seven clinical pharmacists were employed to work across the four pilot sites from April 2016. They are:

  • Two Senior Clinical Pharmacists – Ashfaq Ahmad and Amardeep Singh
  • Five Clinical Pharmacists – Sandeep Khokhar Kapur, Asif Karim, Sheetal Kotecha, Ahmad Hossam Said and Khawer Salim.

Each clinical pharmacist has brought skills and knowledge from a variety of settings from previous studies and past employment.

Many improvements to patient care have been recognised. For this case study we have chosen to focus on the areas where the most impact has been achieved. This includes:

  • Cost - benefit analysis – IntraHealth wanted to see if as well as freeing up GP time, the clinical pharmacists could also reduce the cost of the practice. As well as the financial aspect pharmacists IntraHealth wanted to focus on enhancing the safety of patients by conducting audits, updating policies and many other tasks that contribute to the overall management, which ordinarily would have taken up GP time.
  • Patient perspective – as a forward-thinking company IntraHealth has always employed Nurse Practitioners and Advanced Nurse Practitioners, as part of a multi-disciplinary approach to patient care. As such, patients are used to seeing a mix of health care professionals, therefore the introduction of Clinical Pharmacists into the team was openly welcomed by the patients and other members of the team.

Cost – benefit analysis

Releasing capacity for GPs to allow them to deal with more complex cases

Data collected by the Clinical Pharmacists shows that over 100 hours GP time of direct patient contact was saved (this is based on average 15-minute appointment slots for Clinical Pharmacists), during a three-month period. Clinical pharmacists saw patients for medication reviews, minor illness appointments as well as for the management of long-term conditions.

Over the same three-month period the Clinical Pharmacists were able to save GPs almost 800 hours in administrative tasks such as repeat prescription authorisation, actioning discharge letters and dealing with queries from reception staff and local community pharmacists. A snap shot of the activities the Clinical Pharmacists have engaged in is shown in Figure 1 below:

Figure 1: Activities the Clinical Pharmacists have engaged in

 

 

Additional areas of support / expertise provided

The following list highlights where Clinical Pharmacists have added value to the practice and overall patient care.  This is also shown diagrammatically in Figure 2 below.

  • Monitoring patients with complex long-term conditions
  • Repeat prescribing issues
  • Increasing the uptake of ScriptSwitch® – thereby capitalising on savings for the practices
  • QOF enhanced services
  • Medication reviews / polypharmacy reviews / acute clinics
  • Care home reviews – streamlining ordering processes to reduce waste
  • Discharge reconciliation
  • Conflict resolution
  • Developing local protocols
  • Audits - such as antimicrobial usage, high-risk drugs etc
  • Supporting CCG local incentive schemes by delivering required KPI measures to secure funding
  • Actively engaging with the General Practice Improvement Programme – involvement in multidisciplinary discussions addressing ‘frequent-flyer’ patients’ needs by optimising treatment options and thereby freeing up GP appointment slots

Figure 2:  Reasons for speaking to a Clinical Pharmacist

Figure 3 highlights the potential cost of Clinical Pharmacist (CP) time vs cost of GP time.

Figure 3: CP time vs GP time

Based on the above, it’s estimated that a net saving of £46,800 over the three-month period has been achieved as cost benefit of employing Clinical Pharmacists for the practice and the wider NHS as a result.

Feedback from patients

When asked to rate their satisfaction with doctors, advanced nurse practitioners and clinical pharmacists at the responses were as follows:


 

This is further depicted in Figure 3 below which highlights that a majority proportion of the patient population surveyed this the addition of the Clinical Pharmacist role will be a positive additon the the practice.

Figure 3: Shows the feedback received from patients when asked regarding the introduction of Clinical Pharmacists in General Practice

Overall, the feedback received from the patients has been really positive.  They have welcomed the opportunity to have longer consultations with the Clinical Pharmacists and to be able to discuss concerns they have with their health / medication in more detail that the opportunity allowed during a 10-minute GP consultation.  

Embedding the role in the practice

As discussed in section one above, IntraHealth have been extremely proactive in involving the whole team (clinical and non-clinical staff) in embedding the new posts into the four sites taking part in the pilot.

Over the last 18-month journey, the Clinical Pharmacists are now fully embedded into the practices and are now:

  • First point of contact for reception teams who need advice about prescribing
  • Assisting with communication across a patient’s care pathway, including with GPs, hospitals and social care

Communication

18 months into the pilot, Clinical Pharmacist team are now embedded into the general practice teams. They are regularly contributing to clinical meetings through audits and ongoing review of repeat prescriptions, to ensure all prescribing is safe and appropriate, and highlighting any areas of improvement or learning.

Face to face meetings are held on a quarterly basis and there is regular communication through a local WhatsApp group to share best practice and knowledge.

Clinical pharmacist team receive ongoing support through regular mentoring and appraisals, any areas of development identified through these are then used to formulate their personal development plans, in order that they can continue to grow and develop their current clinical capacity.

in summary, we can conclude that over the last 18 months, the team of Clinical Pharmacists have had a huge positive impact within the four practices that are part of phase 1 of the NHS England pilot.  Through the work that has been carried out, there has been a clear demonstration of:

  • Reducing GP workload and feeing up GP time
  • Improving patient satisfaction
  • Improving patient safety

We look forward to seeing what the next 18 months will bring …

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