Flitwick practice finds clinical pharmacists ease workload, reduce costs and improve safety

4 December 2018
As general practices aspire to greater scale one of their biggest motives is to achieve the skill mix that will both compensate for current shortages of GPs and improve the services received by patients.
 
Clinical pharmacists working in generalpractice are a good example. Good ones can not only save GP time at lower cost but bring new skills and expertise that can help practices run more smoothly and patients to get better outcomes.
 
The programme to put more pharmacists in general practice has already involved several hundred clinical pharmacists and hundreds of practices with more to come. It is among the more conspicuously successful strands of the GP Forward View.
 
Practices were encouraged into the programme on the understanding that NHS England would meet part of the costs of employing pharmacists, with CPPE commissioned to provide clinical training and support and PCC brought in to provide the non-clinical support needed to embed pharmacists in their new roles.
 
Compared with many of her colleagues Sally-Jane Hamilton already knew what to expect from general practice when she arrived at Flitwick Surgery, Bedfordshire.
 
As senior clinical pharmacist, she was responsible not just for getting on top of her new role but for supporting five other pharmacists working in nine practices to get up to speed with theirs.
 
Some with backgrounds in hospital or community services found general practice a shock, she says. “The biggest problem is professional isolation. I’ve formed a network to bring together colleagues in my area – that’s a real help, but it’s also important to work on relationships in the practice, with partners, practice managers, nurses and admin teams.”
 
She can list a lot of other challenges for the new wave of clinical pharmacists, including mismatched expectations, struggles to balance training commitments against salary-paying work for the practice, anxiety on the part of some other staff who may feel threatened by the arrival of a pharmacist and lack of understanding about what pharmacists can bring.
 
Sally-Jane’s surgery is a large dispensing practice with 16,000 patients. It now also has three full-time clinical pharmacists, each dividing their time equally between clinics and administrative work. Various figures have been plucked out of the air to suggest that a single pharmacist could deal with a practice that size or even a locality with upwards of 30,000 patients.
 
Sally-Jane thinks that’s too optimistic. “I’d love to have just 5000 patients to worry about,” she says. “You could make a tremendous difference for a cohort that size.”
 
While practice demographics vary, as arule of thumb around half of patients will be on repeat medications and therefore likely to benefit from interventions by a clinical pharmacist, Hamilton says. That’s a potentially large number of medication reviews and repeat prescriptions to process, but it also represents a big potential time-saving for GPs who no longer have to worry about them.
 
Pharmacist consultations also reduce demand from patients who might otherwise have seen a GP.
 
All three clinical pharmacists at Flitwick divide their time equally between patientfacing and office work.
 
PATIENT FACING
• Minor illness
• Medications review
• Asthma, COPD, diabetes, depression and anxiety review
• Patient education including how to manage their condition, use of medicines and devices, and effective strategies for self-care
• Care home visits (including all the above in a care home setting)
• Home visits
 
OFFICE
• All medication queries (dispensary, doctors, patients)
• Some discharge letters (typically only when complex; otherwise handled by dispensary)
• General prescribing advice to doctors (useful as this is a training practice)
• Liaison with CCG (together with the practice prescribing lead)
• Clinical audits (what are we doing – is it what we should be doing?) looking at safety, costs, clinical aspects
 
The results are impressive. In the first six months, a single pharmacist carried out 1490 tasks that would otherwise have fallen to GPs. Of these 81% required no GP approval or intervention.
 
In the same period the same pharmacist made 1224 clinical interventions including stopping 618 drugs, starting 221 and changing 153 dosages.
 
At the end of two years, by which time the practice had already taken on a second and third pharmacist, there was also a clear impact on prescribing volumes with 79 fewer patients per 1000 having an item on repeat prescriptions and 243 fewer medicines on repeat for every 1000 patients.
 
Sally-Jane sees three big benefits for practices in embedding clinical pharmacists in the team.
 
“First of all, there are cost savings. The care home savings alone could pay pharmacists’ salaries. I am cheaper than a GP, doing things that would otherwise have to be done by a GP, and doing them better than a GP.
 
“Then there is safety. A 10 minute GP appointment may not be enough for a patient on 16 medications. A pharmacist is able to offer 20 or even 30 minute appointments for complicated cases which gives me time to look at everything – why are they taking hay fever tablets all year round? Why are they taking anti-sickness pills when the medication causing the sickness was stopped years ago?”
 
The third benefit, borne out by a patient experience survey earlier this year, is that patients report a positive experience of the care they receive from the pharmacists on the team. When patients were asked to score 11 aspects of their care from 1 (poor) to 7 (outstanding) the mean score for each area was 6 (excellent).
 
Sally-Jane believes that success stories like hers send a clear message to other practices and commissioners about the value of building multi-skilled teams. “Much of our thinking is still organised along traditional professional or contracting lines, but I see a growing enthusiasm on the part of commissioners to promote a more rounded primary care
offering. I want to be part of keeping that change going.”
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