Shailen Rao, Managing Director, and Anna Prescott, Clinical Services Manager at Soar Beyond Ltd, discuss how to successfully integrate a pharmacist into the general practice team and ensure a return on investment

Shailen Rao

Shailen Rao

soar-beyond-jpg

Read this article to learn more about:

  • the benefits of having a clinical pharmacist as part of the multidisciplinary team
  • designing a clinical pharmacist service, and how to recruit the ideal pharmacist
  • how to integrate the clinical pharmacist into the practice and what supervision is required.

This article has been developed in association with Soar Beyond Ltd.

In April 2016, NHS England (NHSE) published the General practice forward view (GPFV), which announced an extra £2.4 billion funding per year by 2020 to support general practice services, with the aim of improving patient care and patient access, and investing in new ways of providing primary care.1 A major element of the GPFV focuses on growing and developing the workforce and honing the skills and experiences of the wider multidisciplinary team (MDT), including a drive to increase the number of pharmacists in general practice to 1500.1 Two years on, following a successful pilot, there are now approximately 580 clinical pharmacists working in general practice with approval to fund more posts in the pipeline.2

With retention and recruitment of GPs and nurses causing ongoing strain in general practice, the opportunity to obtain funding for 3 years to recruit, train, and establish clinical pharmacists into the MDT offers a potential solution. However, the implementation of pharmacists across multiple practices, particularly to the ratio outlined by NHSE of one pharmacist to 30,000 patients, is not without its challenges. This article discusses how to overcome these challenges.

The role of the clinical pharmacist

What can a pharmacist bring to my practice and how will I show a return on investment?

For practices that have never worked with clinical pharmacists, views about the role of the pharmacist are often influenced by what they see in community pharmacy. The role that a pharmacist takes in general practice is very different to the community pharmacist role and adds significant value to both the practice and, more importantly, to patients. Roles can range from running clinics to supporting integration and the overall medicines optimisation agenda at practice level as outlined in Figure 1.

Figure 1 What can a clinical pharmacist do in general practice

Figure 1: What can a clinical pharmacist do in general practice?

QOF=quality and outcomes framework; CQC=care quality commission

This variety of activities, alongside the varying backgrounds of pharmacists, can prove challenging to practices even knowing where to start. If a practice is expected to share a pharmacist across multiple sites, the following questions are often raised:

  • what is the best use of a pharmacist’s time?
  • what is a pharmacist competent to deliver and how can their competency be assessed?
  • how is a pharmacist going to deliver what is required by each practice when they are spread so thinly?
  • how can a pharmacist be supported?
  • how will success be measured and the post funded in the long term?

Although the overarching message of having clinical pharmacists in general practice is a positive one, setting up the service for success can prove challenging, and with the day-to-day pressures of general practice, it is often difficult to find the headspace to think through how the clinical pharmacist service should look. This can frequently result in pharmacists starting their role in general practice with minimal guidance and carrying out activities that are outside of their scope of competence—a risk to both practices and patients.

Setting up and mobilising clinical pharmacist services

1. Designing the right service

Organisations that have been successful in obtaining funding via NHSE are faced with the challenge of devising a model that enables each pharmacist to work equitably across multiple practices to serve 30,000 patients. This requires consideration of each practice’s list size, internal capacity, the needs of each practice population, the share of the pharmacist’s time, and the practicalities and time constraints of travelling between sites. A pharmacist is an asset to general practice, and if modelled appropriately, services can be delivered well and at scale (see Box 1). 

Box 1: Top tips for sharing a clinical pharmacist

  • Establish shared goals and needs that can be done at scale
  • Be prepared to compromise
  • Work together and share roles
  • Do not expect the pharmacist to be able to do everything from day one
  • Continually review the balance of work.

Practices independently employing their pharmacists may not have the same stretch in terms of patient cover but will be challenged by the fact that they have no funding to support the recruitment, training, and development of their pharmacist. There will therefore be more financial pressure to ensure the recruited pharmacist can deliver what is required as early as possible.

Regardless of whether funding has been secured or not, it is essential to establish, from the outset, what the practice wants to achieve from having a clinical pharmacist as part of the MDT. This will help to:

  • effectively plan what the pharmacist can and will do from day one
  • identify what resources and training will be required to upskill them to the desired level in both the near and distant future
  • clarify the desired outcomes to ensure a good return on investment.

2. Recruiting the right pharmacist(s)

When recruiting a pharmacist to join the practice, it is necessary to identify what they can offer that is different to the existing skillset within the MDT, while also meeting the practice’s needs or expectations right from the outset. 

Pharmacists do not all have the same level of competency or experience; what they can and cannot do will depend on the sector(s) they have worked in before joining the practice. When recruiting and mobilising a pharmacist, it is important to consider:

  • is their experience relevant to the role?
  • do they have the right skillset to meet current and future needs?
  • are they competent to deliver what they say they can?

Pharmacists are highly skilled professionals who have trained for 5 years to obtain their qualifications and are often described as experts in medicine. Focus on roles within the practice that they can easily transition to regardless of the sector they have come from. This may include medication review clinics, polypharmacy clinics, and medicines reconciliation post discharge. The patient-facing role can then be further developed with the right level of support, supervision, and training to fulfil the longer-term needs of the practice.

Some pharmacists will have an independent prescribing qualification; however, this does not mean they can prescribe everything. Establishing the pharmacist’s scope of competency at the beginning will help mitigate the risk of them working outside of this and potentially compromising the safety of patients. 

Box 2: Top tips for recruiting the right pharmacist

  • Understand and agree in advance what the organisation/practice wants in the short, medium, and long term from a clinical pharmacist
  • When selecting CVs, look for pharmacists who have the relevant experience and skills to (at least) fulfil short-term needs
  • At the interview stage, use questions that help assess key skills—prioritisation, clinical knowledge, and decision making
  • Consider having a pharmacist on the interview panel (preferably, but not necessarily, a clinical pharmacist)—they can provide insight into how the candidate’s background and qualifications will be beneficial to the role.

3. Induction

A thorough induction is key to ensuring a smooth transition for any clinical pharmacist, but particularly for pharmacists who will be working across multiple practices (see Box 3). Working together from the outset and sharing roles can make this much easier for both practices and pharmacists. For example, one practice may take ownership of mandatory training, while another practice may focus on collating relevant paperwork, setting up email addresses, and so on. This will prevent duplication of work and provide some assurance to the pharmacist that the practices involved have a shared agenda right from the beginning. 

For pharmacists who have not worked in primary care, it will be necessary to provide education on the intricacies involved in both running a general practice as a business, and also how clinical care is provided, funded, and reimbursed—every attempt should be made to incorporate this into the induction. 

Box 3: Top tips for inducting a clinical pharmacist

  • Develop a clear and structured induction plan in advance of the pharmacist starting
  • Share roles among practices where relevant
  • Use a checklist to ensure all areas are covered by funding
  • Provide resources and education on GP contracts and streams
  • Arrange shadowing with relevant members of the MDT in advance of the pharmacist starting.

4. Supervision

Despite their extensive knowledge of medicines, many clinical pharmacists will be new to general practice and will have little or no experience of clinical assessment in consultation. Practices therefore need to invest in the right level of support early on in the pharmacist’s journey as this will ensure safe delivery of service and better outcomes later down the line (see Box 4).

Pharmacists who are employed as part of the NHSE programme will be enrolled on to the Centre for Pharmacy Postgraduate Education training pathway, which provides a structured training programme with support from an educational supervisor and attendance at training days. Input will be required from the practice to sign off competencies and skills as the pharmacist develops in practice, as well supporting the pharmacist to complete their independent prescribing qualification, and providing day-to-day clinical support.

To qualify as an independent prescriber, pharmacists must be supervised by a designated medical practitioner. This will require time and resources from the practice to release the pharmacist for face-to-face training, self-directed study, and 12 days of direct supervision by a GP.3 Ultimately, this will enable the pharmacist to significantly expand their patient-facing role and potentially free up practice capacity later down the line so it is well worth the investment.

Pharmacists who are employed without NHS England funding support may not have access to the national training pathway, so it is therefore essential that the practice fully understands what their pharmacist is competent to deliver, and the pharmacist should have the evidence to demonstrate. Structured support and assessment should be incorporated into the pharmacist’s development plan and indemnity should be scrutinised for all activities they will be undertaking to ensure that they and the practice are sufficiently covered. The Royal Pharmaceutical Society foundation level framework,4 advanced level framework,5 and prescribing competency framework6 are a useful starting point when looking at overarching competency and are relevant across all pharmacy sectors.

Box 4: Top tips for pharmacist supervision

  • Assign a clinical supervisor who will oversee pharmacist development
  • Ensure regular and protected time for de-brief/feedback
  • Enable an open-door policy or designated support for emergencies/queries
  • Ensure the pharmacist has clear, achievable, and measurable objectives
  • Plan supervision into the diary (for both the GP and pharmacist)
  • Agree a suitable method of assessment where relevant.

Summary

When clinical pharmacists are set up, inducted, and supported effectively they will be an asset to any practice team. A clinical pharmacist will be able to take on roles ranging from: medicines administration, clinical delivery, process improvement, and cross-sector integration. Figure 2 shows an example timeline for a non-prescribing pharmacist, from embedding into practice right through to monitoring and assessing performance.

It is important to agree with key stakeholders to determine how the pharmacist service will work within the practice, how supervision will be provided, and what the crucial objectives are before proceeding to recruitment and selecting a pharmacist. This is vital for ensuring a successful start to the clinical pharmacist’s journey, and in establishing a service that will be of benefit to both practice staff and patients.

Figure 2 soar beyond SMART clinical pharmacist solution

Figure 2: Soar Beyond SMART clinical pharmacist solution

CCG=clinical commissioning group; PPG=patient participation group; LTC=long-term conditions; PH=public health; KPI=key performance indicator

Notes from the author

I started my career as a clinical pharmacist some 20 years ago. My company, Soar Beyond, has over 10 years of practice-based pharmacy experience and is a Wave 1 NHSE Clinical Pharmacist provider in North West London. Soar Beyond has extensive knowledge of the challenges of setting up and embedding clinical pharmacists from both a GP practice and pharmacist perspective, and supports NHS sites to deliver their clinical pharmacist services using the SMART model which comprises:

  • Set-up and Mobilisation of the clinical pharmacist service—developing the right service model and recruiting the right pharmacist with a robust induction
  • Acceleration—rapidly embedding the clinical pharmacist as part of the MDT and leveraging their skills to catalyse outcomes
  • Resources and ­Training—supporting the upskilling of the clinical pharmacist through tailored training and support that minimises time away from practice.

Look out for a follow-up article in next month’s issue of Guidelines in Practice that will discuss how, once a pharmacist has been recruited, to rapidly accelerate their development while ensuring patient safety and achieving a compelling return on your investment.

Shailen Rao, Managing Director of Soar Beyond Ltd

References

  1. NHS England. About the GP Forward View. www.england.nhs.uk/gp/gpfv/about/ (accessed 6 August 2018).
  2. NHS England. Clinical pharmacists in general practice. www.england.nhs.uk/gp/gpfv/workforce/building-the-general-practice-workforce/cp-gp/ (accessed 6 August 2018).
  3. Pharmaceutical Journal Online. How trainee pharmacist independent prescribers can work with their supervisors. Available at: www.pharmaceutical-journal.com/careers-and-jobs/careers-and-jobs/career-feature/how-trainee-pharmacist-independent-prescribers-can-work-with-their-supervisors/20068988.article?firstPass=false (accessed 6 August 2018).
  4. Royal Pharmaceutical Society. Foundation pharmacy framework (FPF). www.rpharms.com/resources/frameworks/foundation-pharmacy-framework-fpf (accessed 6 August 2018).
  5. Royal Pharmaceutical Society. Advanced pharmacy framework (APF). Available at: www.rpharms.com/resources/frameworks/advanced-pharmacy-framework-apf (accessed 6 August 2018).
  6. Royal Pharmaceutical Society. Prescribing competency framework. www.rpharms.com/resources/frameworks/prescribers-competency-framework (accessed 6 August 2018).