Posted by: Niketa Dass27 NOV 2019
A randomised controlled trial published in 2001 showed that pharmacists working in general practice can conduct effective consultations and, in 2015, a pilot project by NHS England echoed this benefit.
Now, in 2019, there are more than 1,000 full-time equivalent clinical pharmacists working in primary care across England, and the NHS is committed to recruiting many more.
I became curious about a GP pharmacy role after originally training in hospital pharmacy, and in 2017, began working as a clinical pharmacist across three GP practices, while enrolling myself onto an 18-month ‘Clinical pharmacists in general practice education’ programme. But once the course was over, I was left feeling isolated. There is no formal mentoring method upon completion of the course — pharmacists are left to their own devices.
I thought about clinical supervision, a driver of significant improvement in the process of care, which may improve adherence and patients’ subsequent health outcomes. It can also drive higher levels of job satisfaction and can help staff to manage the emotional impact of their practice.
I contacted an ex-colleague, Nina Barnett, who kindly agreed to be my mentor; to review and reflect on challenging patient cases with me, and deliver some joint clinics together — our meetings were invaluable.
During a joint consultation, we saw Mr W, who was accompanied by his son. Mr W has early dementia and lives alone. His son was worried that Mr W forgets whether he has taken his tablets, possibly resulting in double doses. His son and I agreed that I’d make a medication reminder sheet for Mr EW but, after four weeks, he had not collected it.
On reflection, I didn’t ask how Mr W was feeling about his adherence and what he wanted to do about it. I could have asked him if he had any ideas about what to do, and then offered him a medication reminder sheet, agreeing to review it with him after four weeks. This way the patient would have had choice and control, and his son would have been assured that his concerns were being taken seriously. Putting the patient at the centre of the conversation would have led to a collaborative, agreed solution.
We also saw Miss Y for a contraceptive pill review. Usually, I would run through what we were going to discuss and then ask questions directly related to the pill, but Nina suggested that I ask Miss Y what she wanted to discuss.
She mentioned her polycystic ovarian syndrome (PCOS) and that she wanted to take metformin rather than the contraceptive pill. I asked her to tell her story from the start, leading her to share her current social situation, weight gain and mood, and us building a rapport during the consultation.
She revealed a five-year history of anhedonia — an inability to feel pleasure in usually pleasurable situations. She also had some suicidal ideation, with no plans. I referred her to a counselling service and discussed this with the GP. I made a GP appointment for her in two weeks’ time and gave her some information about PCOS and metformin.
By addressing the patient’s agenda early in the consultation, it became clear that there was important background information to her complaint. Exploring the impact of PCOS on her mood helped her to open up, and asking her to tell her whole story, using the topic; goal; reality; options; and wrap-up coaching model, meant that we quickly gained a lot of insight, resulting in us giving her the information she needed, and an appropriate referral.
Previously, I would have focused on completing the pill review template, and I might have been frustrated that the patient wasn’t focused on it too. We would not have built rapport and she may not have listened to me because I wasn’t listening to her.
After the consultation, Nina and I discussed how it made us feel. We were both moved by the patient’s situation and both needed a few moments to ‘reset’ before the next patient.
Back-to-back consultations is routine practice in a clinic, but I wasn’t used to it when I first started — it was emotionally challenging and isolating. Reflecting with a mentor has been so important to me. It has helped me to process the feelings that patients can evoke during consultations, and now I can leave those feelings at the practice when I go home.
If we are going to practise pharmacy the best we can, we must support pharmacists’ mental health and nurture a resilient workforce — we need mentors.
Niketa Dass, clinical pharmacist, Hampstead Group Practice, Keats Group Practice and Park End Surgery, London
Acknowledgement: Nina Barnett, consultant pharmacist for older people, London North West University Healthcare NHS Trust, London (a coach and mentor who develops and delivers training in person-centred care and shared decision-making for pharmacy practice)