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UK healthcare

Q&A: How do GPs view the role of pharmacists in the NHS?

London-based GP Clare Gerada is chairman of Clinical Board, Primary Care Transformation, NHS England (London Region). But she is probably best known for her work as chairman of the Council of the Royal College of General Practitioners, a post she held for three years. She shares her thoughts on the role pharmacy should play in UK healthcare.

Clare Gerada, GP and chairman of Clinical Board, Primary Care Transformation, NHS England (London Region)

Source: Elizabeth Sukkar

How can pharmacists raise its profile in the NHS and to the public?

They already have a profile with the public. There are more people going into pharmacies than going into GPs per day. But pharmacists need a review of how they can best use their skills. With the modern systems, such as original packs for dispensing, automatic dispensing, they’re no longer making up your creams and potions. The need for a pharmacist at the back of the counter is now increasingly redundant and they should be at the front of the counter, or even out of the shop. On a side note, the way pharmacists are paid is an anomaly; they’re paid in the same way as they were paid in 1947. They should have a registered list, like GPs; they should [be managing] long-term conditions and they should be paid in a similar way to GPs.

What do GPs see as the main role of pharmacists?

It is important for pharmacists to review their own contractual arrangements — it is not for GPs to dictate how they should work. Pharmacists should set the clinical standards, set their own commissioning specifications, and then decide what it is they should be delivering to patients and the public. I don’t think pharmacists are trained to manage risk and uncertainty, and therefore encouraging the public to attend in large numbers when they have got a sniffle “just in case” is only going to increase demand for GPs since many of these patients will be asked to attend their GP for a follow up. Pharmacy’s role is around supporting concordance with medicine and supporting long-term conditions. But I am not sure pharmacists, or doctors in fact, have the skill to stop medicines. If there is a patient on 15 medicines, pharmacists aren’t going to stop any of them because where would they start? Pharmacists have to be honest about where they can add value.

But many pharmacy bodies are saying pharmacists can help with minor ailments…

If the public start attending pharmacies in large numbers, pharmacists, like GPs, will have to learn to manage risk and uncertainty. Once patients visit pharmacists in anywhere near the numbers they attend their GP for clinical issues, then they will have the same problems that GPs have, in that they are seeing things too early on. It is the hardest job on earth to manage risk and uncertainty. All pharmacists will end up doing is referring them or asking them to come back another time. Pharmacists have to start doing integrated work with GPs or at the patients’ homes.

Where do you see the collaboration between GPs and pharmacists?

I would love a pharmacist to tell me: “There is no point with this patient being on seven different medicines because each one of them… .” I have never heard a pharmacist in the community say to me: ‘I suggest you stop this medicine. I suggest these two medicines work in the same [way].” It is not us [GPs] who puts them on this rubbish, it is the hospital doctors. So what we have is this problem of hospital doctors initiating a large number of medicines – of which much is of dubious value to the patient. We have to prescribe them and the pharmacist has to dispense it. Wouldn’t it be great if the pharmacist and GP were empowered to say “Let’s do a fundamental review of this patient’s medicines. Let’s look at how we can manage it jointly.” I have worked with pharmacists brilliantly in the past around substance misuse management — unbelievably helpful — and depression management.

How about pharmacists working in accident and emergency departments?

I am not sure what training pharmacists have to see patients in emergency departments. Maybe I am behind the times. But unless you are all trained as omni-competent GP-pharmacists — and even then — I’m not sure how pharmacists can do our job. It looks so easy on the outside to distinguish between three sore throats that come in but one might be cancer, one might be hysteria, and one might be tonsillitis.

In August 2014, GPs complained about pharmacists taking away their revenue for the influenza vaccine and the service was decommissioned because of the complaints. Do you agree with the concerns of the GPs?

It might be important for pharmacists to look at what they are doing in their own profession before stepping on GPs’ toes. There is enough work for all of us to do. I just don’t see why pharmacists pick on the bits that we GPs do well and why don’t you find the bits that you do well.

And what bits do you think pharmacists do well?

Pharmacists do medicines reconciliation incredibly well. Why don’t they liaise with hospitals before patients are discharged? Why don’t they go into hospitals even before they’re discharged and put them directly on to the record? Why don’t they reconcile the hospital record with the GP record when a patient comes out? Also, I have seen the skills that pharmacists have in patient engagement. They have phenomenal skills and they are untapped. The pharmacy-patient relationship is fantastic so pharmacists can do something around long-term disease management in patients’ homes. Pharmacists should be doing more home visits, more case management because that is what they are good at.

GPs make up a majority of members of the clinical commissioning groups. Do you see any conflicts of interest when commissioning services and are they skewed towards GPs?

Of course they are, but there is enough safety [in the system]. GPs do 90% of the healthcare so why not. I very much prefer that it is skewed towards GPs rather than to cardiothoracic surgeons, for example, who might not have a helicopter view of public healthcare. GPs have their fingers on the nation’s pulse. With about 400 million patient contacts per year, and each one bringing on average three problems, that’s a billion problems. The rhetoric of the primary care-led NHS is the right rhetoric and pharmacists have a vital place on that. I wish that pharmacists and public health were also part of that. So GPs, pharmacists and public health would make the perfect triad. The more I am around pharmacists, the more skilled I find them to be, and the more I wish they could have the time to come out of the dispensary. They help so much and the pharmacists in my life have saved me umpteen times.

 

Interview by Elizabeth Sukkar

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2015.20067872

Readers' comments (7)

  • Dr Gerada talks complete sense about where and how Pharmacists can add real value to patient outcomes. Get out from behind the counter and engage with patients.

    She also makes a good point about us designing our own contract. The perverse one we have that encourages community pharmacists to maxImise costs to the NHS rather than incentivise us to find savings is untenable.

    I know this is uncomfortable reading for community pharmacists, especially owners but we need to focus on flesh and blood (pharmacists) not bricks and mortar (pharmacies) if we are to realise our potential and become a fully functioning part of the primary care team

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  • Andrew Low

    It is good to see Dr.Gerada talk to the Pharmaceutical Journal.You can read that she has a lot of time for pharmacists (she's pro-pharmacy).
    She is someone who actually replied to my letter on Sahaja Yoga when she was the Chair at the Royal College of General Practitioners.
    Sahaja Yoga is free and to my mind it is surprising that more health professionals don't embrace it,this seeming an obvious thing to me.
    Dr.Ramesh Manocha,a GP and researcher at the university of Sydney in Australia,wrote a book "Silence Your Mind" with mentions and references.
    I had a letter in the Nursing Standard in October 2014 on the subject of spirituality in healthcare.
    Dr.Gerada also thanked me for "by the way" comments I included about my schizophrenia and how reading and Sahaja Yoga were supports.There is the "repressive cough" of the bully in the novel The Cruel Sea by Nicholas Monsarrat,or "cross little cough" in Alexander Pushkin.
    Sahaja Yoga is something that definitely needs to have explosive growth,as the guru Shri Mataji Nirmala Devi said,and needs to cross the pharmacy and other counters and go into the public domain,one's countrymen and women are waiting.

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  • I read the interview with Dr Clare Gerada and the responses from Shaun Hockey and Andrew Low with much interest. I just wish that I was as convinced that Dr Gerada's model is as beneficial to pharmacists as they seem to.

    First,concerning the Influenza vaccines: I have spoken to another practising pharmacist and also done an online search and nowhere can I find any reference to the pharmacy vaccination scheme being decommissioned due to complaints from GP's. That aside, Dr Gerada asks "...why pharmacists pick on the bits that we GPs do well and why don't they find the bits that they do well"

    The bit that pharmacists do well in this case is provide a vaccination service more or less on demand, out of hours (at 101 hr and some other pharmacies) and at weekends, all for typically £9 unless under a PGD, paid for by the patient thereby relieving the NHS of a bill. Compare this with the bit that GPs do well in this case which in many areas is to get the practice nurse to administer the vaccine, paid for by the NHS, at daytime clinics.

    Dr Gerada claims "...I am not sure that pharmacists, or doctors in fact, have the skill to stop medicines. If there is a patient on 15 medicines..." If the patient is on 15 medicines then it does seem that it is the medical profession that has initiated the prescribing of them. Surely the GP should be the one to query Rx of hospital Drs?

    I could write much more but it does seem that the Dr Gerada model for the future of pharmacists is, in essence, that we go around tidying up prescribing, paid on a capitation basis like GPs. I would very much like to see how the capitation fees would be evaluated and the likely income derived from them.

    Dr Gerada has been described as one of the 100 most influential women in London. I rather hope, for the sake of the next generation of pharmacists that she uses her influence as one described as a friend of pharmacy to find a much wider role than the one described here.

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  • Dr Gerada makes some pertinent comments about the overdue review of the community pharmacy contract and I agree with the need for CPs to be away from the back of the dispensary and visible and available for advice at the front. Making flu vaccination available in pharmacies increases accessibility and uptake, a public health imperative, and therefore in-keeping with pharmacy services.

    I disagree that pharmacists aren't trained to assess risk. However inexperienced pharmacists may be more risk averse, and supervision and peer support for early years community pharmacists (who are often the sole pharmacist on duty in the pharmacy) is a key development area. More experienced community pharmacists are practised in assessing and referring as appropriate and I believe could work as part of a multi-disciplinary team in A&E.

    However, not all pharmacists are community pharmacists, not even in primary care! In many areas General Practices have had support pharmacists working with them for years, many also as independent prescribers. These practice pharmacists are well placed to review medicines and suggest those that may be appropriate for stopping, in fact something I was doing 10+ years ago.

    The RPS is doing a good job of promoting the skills and expertise of pharmacists and I think we all have a duty to do so at each and every interaction with the public, GPs, nurses and other healthcare professionals.

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  • I would like to echo Cathy's comments around the capability of community pharmacists and their ability to risk assess before referring or not as appropriate.

    The truth of the matter is that with appropriate access to patient records, an appropriate remuneration package and suitable competence based training pharmacists are perfectly capable of working as part of the multidisciplinary team. We have demonstrated this very well in the hospital setting in recent years but not in the community.

    In fact with little more than an incomplete prescription record I think community pharmacists don't do too badly at all.

    The use of pharmacists in the community to reach, engage and manage patients by prescribing is almost completely under-utilised for a number of historic well discussed reasons.

    The real benefit of pharmacists in GP practices could be to highlight and champion the good work done in the community setting where in my view the greater opportunity lies.

    I agree with the sentiments above in that with a little more autonomy and a secure connection to the multidisciplinary team community pharmacists could deliver significant returns.

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  • As a GP I know that Dr Gerada's main contact will be with community Pharmacists. However, even though she comes across as 'pro' pharmacy she describes a complete lack of regard for the role of the hospital pharmacist. Her statement, "patients are sent home on large numbers of medicines that add dubious value" suggests that ward-based hospital pharmacists do not review patients medicines and allow doctors to prescribe whatever they want. As a highly Specialist hospital pharmacist I ensure that medicines I recommend or even prescribe myself have a need and with regular attendance on Consultant ward regularly review which medicines are no longer required. While patients are acutely unwell in the hospital setting medication regimes may change dramatically.
    I do not think it is fair for her to say that it is not GPs that put patients on "rubbish" medications but the hospital doctors. I have plenty of examples of GPs prescribing inappropriate medications for my patients. As a prescriber myself I have a clinical responsibility to question the need for a medicine. If GPs have concerns or queries regarding medicines they should be liaising with the Specialist team not blindly prescribing. Passing the blame is not the answer we should be working together across primary/secondary care boundaries to ensure patients are on the appropriate treatment and minimising the risk of harm.

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  • We must move away from medics and pharmacists working in silos driven by egos, historic baggage and contractual arrangements.

    The time has come for the NHS and public health to put the patient/individual at the centre not the system. This requires contractual reconfiguration that is aligned to the needs of the population with truly joined-up care. https://cms.pharmaceutical-journal.com/CMS/commentEdit.aspx?label=comment&id=1009789&TB_iframe=true&width=650#

    A good start is for pharmacists operating in all sectors to work together enabled by strong and effective leadership and dropping the hierarchical pretences sometimes exhibited. One profession, one goal - optimising patient care and outcomes as part of a multi-disciplinary team.

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