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Pharmacy must grasp new clinical opportunities with both hands

As a GP with 25 years’ experience, a strong interest in medical education, and married to a community pharmacist, I am constantly amazed by how pharmacy has allowed itself to be sidelined and passed over by other medical-related professions. Salaries have not kept pace with similar groups, and there has been little in the way of role development and extension of skills. What few initiatives there are, such as minor ailment schemes, have been piecemeal and under-resourced.

The nursing profession, by contrast, has seized its opportunities and gradually evolved, gaining hugely in role, respect, and thus remuneration. When I first started to work in general practice the then few practice nurses were employed mainly to change dressings, conduct phlebotomy, give vaccinations and other somewhat menial clinical tasks. By undertaking courses supported and approved by the Royal College of Nursing, this extended into chronic disease management of conditions such as asthma and diabetes, and then, increasingly, into their own clinics undertaking triage and minor ailments.

Nurses were fast adopters of prescribing and were granted these rights in 1992 (pharmacists did not gain this until 2003), initially as supplementary and, later, as independent prescribers. Nurses then went on to develop the nurse practitioner role, functioning relatively independently within surgeries, seeing a wide variety of patients limited only by their own experience and confidence. Skill mix changes then saw practices training up administrative and reception staff or recruiting school leavers to become healthcare assistants, who now undertake the tasks such as dressings, phlebotomy, electrocardiograms, spirometry, etc, that nurses have now outgrown.

There is a huge shortage of GPs nationwide, with up to 30% of practices currently reporting unfilled positions, and a number of practices closing down or being taken over when shortages prevent them from providing a service. Nurses have moved to fill this opening with further development into advanced clinical practitioners (ACPs), often providing much the same service as the GPs, including twice daily surgeries, home visits and a share of the on-call rota. Salaries above £50,000 are now commonplace for advanced nurse practitioners (ANPs), and they are treated by patients and colleagues alike as members of the doctor team. This has been made possible by the formation of ANP and ACP training courses, with modules such as prescribing, diagnostic skills, acute disease management, encouraged and supported by the Royal College of Nursing.

The Royal Pharmaceutical Society (RPS) seems to have seen the light, and I was extremely excited to have been awarded with a contract to host one of the ‘clinical pharmacist in general practice pilot’ pharmacists in my group of practices. This scheme aims to encourage the placement of experienced pharmacists into general practice and use their prescribing, consulting and management skills within surgeries.

However, having now seen the limited information available, it seems the aim after three years of in-practice training is for these pharmacists to undertake medication reviews and chronic disease management clinics, something our junior nurses already perform for a fraction of the salary. This scheme is undervaluing the skills pharmacists have to offer in general practice. It should have an aim of creating pharmacist advanced clinical practitioners operating independently to diagnose, investigate, treat and refer patients as appropriate.

The pilot appears to have some major flaws. There is, as yet, no curriculum, no set of standards, and no assessment mechanism. This is easily achievable by using the best practice examples of the ACP training schemes, or the Royal College of General Practitioners’ registrar’s curriculum and e-portfolio system of regular assessed consultations, case-based discussions, reflective learning, etc. More importantly, with pharmacists already appointed to some pilots, no one seems to have even considered the provision of medico-legal legal indemnity for this role. The Medical Defence bodies, which allow nurses and ACPs to be covered under GP practice schemes, have no provision for the participants on this scheme.

Community pharmacy needs to act quickly to halt its decline and regain its respect or it will continue to deteriorate into the role of glorified shopkeepers. Political leadership needs to talk to those of us outside the profession who want to help, and can offer practical advice before it is too late. Defending what pharmacy historically was, and to some extent still is, is not good enough – the future requires open mindedness and the ability to change and develop.

Tim Parkin

GP Partner

Limes Medical Centre

Alfreton, Derbyshire

Citation: Clinical Pharmacist DOI: 10.1211/CP.2016.20200979

Readers' comments (3)

  • A very stimulating letter from a clearly forward thinking GP with a "big picture" view of the healthcare landscape. I was particularly taken by Tim's line "Political leadership needs to talk to those of us outside the profession who want to help". Hopeful this clearly genuine offer of help from Tim and individuals like him is taken up.

    I am a partner in a small, employee owned, group of Community Pharmacies in London. We are clinically, not retail focused. When we set up 17 years ago we made a conscious decision to not sell cosmetics and perfumes etc and by doing so we have been able to focus on our clinical offer, allowing us to deliver many innovative services. When we made this decision we wanted to send out a clear message to our patients and the commissioners that we are healthcare professionals not a retailer / shop keeper as well. As a result of this we had a platform to expand from Community Pharmacy to additionally deliver educational services, including setting up with UCL the first undergraduate Community Pharmacy teaching Practice in the UK, we have also been commissioned to deliver several post-graduate and multi-disciplinary courses. Recently we have further expanded to deliver Practice Pharmacist services to several GP Practices and GP Federations.

    It has not been easy to enter these new arenas, and it required a lot of investment on our part, but as Tim says "the future requires open mindedness and the ability to change and develop." Fundamentally this is a business decision for individual pharmacies to make, but it seems to me we are at a cross roads and we need to decide which path to take. The cuts community pharmacy face are severe but perhaps by taking up Tim's gauntlet and grasping these clinical opportunities there is a way forward.

    Sanjay Ganvir
    Partner and Director
    Green Light Healthcare

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  • Medicines Specialist Practitioners - Helping GPs eat the elephant in the room

    As a senior pharmacist with 25 years hospital experience ( 10 as an independent prescriber ) who is about to take up a role as a NHSE funded clinical pharmacist in general practice I feel the need to respond to Dr Tim Parkin’s warning about pharmacists’ missed clinical opportunities.1
    As he says the patients served by general practice are in need of assistance. One of the key reasons for this has been 25 years in the making, and is due to the ever increasing numbers of patients with multi morbidity and inappropriate (hyper) polypharmacy.
    With more than a billion prescriptions issued, and an estimated 600 000 non-elective hospital admissions due to sub optimal use of medicines, every year in England 2, this “elephant in the room” cannot be ignored any longer. The subtlety and complexity of medicines and the increasing amount of aimless “NICE endorsed”, and specialist “silo prescribing” in hospitals means medication review, in line with patients / carers wishes, by medicines experts in primary care is now essential.
    Ask any older patient and they will always say “I want to take fewer pills” and invariably there are always some that can be safely stopped. However this type of work is currently difficult to achieve in general practice due to a lack of dedicated time and appropriate specialist skills but will become the focus of these pharmacists.
    As the GP trainer on the excellent Centre for Pharmacy Postgraduate Education (CPPE) training course said, this new cadre of clinical pharmacists in general practice are “neither cheap doctors nor expensive nurses” and I believe they should be thought of as a dedicated team of medicines specialist practitioners (MSP’s). Their primary aim will be not to diagnose acute illness but rather to ensure those with chronic diseases don't become acutely unwell due to preventable adverse effects of unnecessary, or non-adherence to, medicines.
    I am absolutely certain that GP colleagues lucky enough to have one will soon realise just how indispensable MSPs, like their advanced nurse practitioner (ANP) pioneers before them, are for providing better patient care.

    Steve Williams

    1 Parkin T. Pharmacy must grasp new clinical opportunities with both hands. Clinical Pharmacist May 2016.

    2 Medication Safety in the NHS infographic faults and remedies NHS England March 2015

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  • I recently tried working at a GP practice in Chester. I thought my role was to be the Pharmacist responsible for investigating polypharmacy in the elderly who had not been reviewed in the previous twelve months by the GP, making recommendations where possible to reduce this, provide medicines education and improve compliance and of course refer to appropriate practitioner if urgent care needed etc etc...all the issues that you would expect a pharmacist with 20 years experience obtained across various clinical roles to be able to undertake with ease and without question.
    After 6 months I was told that I was no longer " financially viable" and that the part-time Medicines Manager ( newly promoted from reception clinical knowledge!!) was in fact capable of providing this role!!!!
    I was told that in was in fact my " job " to count the tablets that the patients were asked to bring along to the appointment ( which the majority of patients did not, due to the sheer volume that they had or for fear of being mugged....seriously!!) and organise a reconcilliation prescription (that I was told by the Lead GP not to print and forward for signature one day but then moved the goal posts to suit and changed his mind on a weekly basis!!!)
    Sorry for the rant but I just hope that some GP's open their eyes and see that sometimes they can be their own worst enemy.
    The practice manager who shall we say "let me go" ( also new to role with no previous GP practice management experience) had no idea what my role involved and just saw the invoice ( four hours once a week) and decided I was a luxury they couldn't afford).
    I agree that training pharmacists to undertake these roles is a brilliant move forward for our profession but if the management team within the practice are not educated before we take up these roles then we face yet another uphill struggle....
    It is not all about quantity of patients assessed on a daily basis but the quality of the assessment provided ( does this sound familiar?? MUR targets in Community)
    I know for a fact that in my short stay at the practice I prevented numerous potential falls and many hospital admissions amongst my elderly patients...none of which obviously appeared on the "financially viable" spreadsheet.
    All I can say is I am sorry to the patients that I was not given the opportunity to assess...I wish them luck for the future.

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