Shailen Rao, Managing Director, and Anna Prescott, Clinical Services Manager at Soar Beyond Ltd, explain how to accelerate the development of a clinical pharmacist in general practice

Shailen Rao

Shailen Rao

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Read this article to learn more about:

  • the varying competencies of clinical pharmacists (e.g. prescribing versus non-prescribing pharmacists)
  • supporting a clinical pharmacist to become fully embedded in the practice and add maximum value
  • how to measure the impact of the clinical pharmacist on workload, patient outcomes, and other key metrics that matter to the practice.

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

In their previous article, Shailen Rao and Anna Prescott discuss the roles of a clinical pharmacist in general practice and provide insight into how to successfully set up and mobilise a clinical pharmacist into the practice multidisciplinary team (MDT). In this article, the authors focus on the importance of accelerating the development of the clinical pharmacist once in post, providing practices with a return on investment while reducing workload and maintaining patient safety.

In 2018, The University of Nottingham published a report evaluating the NHS England Phase 1 Pilot to integrate clinical pharmacists into general practice. The report discusses how clinical pharmacists made an impact in the following areas:1

  • capacity and workload
    • freeing up GP time by taking on routine tasks such as medicine reviews, prescription requests, and managing discharges
    • increasing patient access to appointments as GP capacity is released
  • medicines optimisation and safety
    • implementing previously unimplemented NICE guidance for prescribing in long-term conditions 
    • reducing prescribing errors and increasing strategic prescribing.

The report also highlights the positive impact the introduction of clinical pharmacists has had on both themselves as professionals as well as their patients:

  • professional impact
    • high level of job satisfaction
    • clinical pharmacists enjoyed the opportunity to work clinically within a MDT and utilise their specialist skills in medicines
  • patient feedback
    • patients appreciated tailored and variable appointment lengths with a clinical pharmacist as they felt it allowed for an in-depth review and holistic care
    • patients felt they had a better understanding of medicines and health
    • patients reported improved medicine adherence and appreciated efforts to de-prescribe
    • patients compared the service favourably with GP appointments.

These are extremely positive outcomes for both the pharmacy profession and GP practices, where maintaining an effective workforce remains an ongoing challenge.

To realise these benefits quickly and make the most of a clinical pharmacist’s skillset, it is important to answer some key questions when planning the clinical pharmacist service:

  • what does the practice need now and in the future?
  • what competencies does the clinical pharmacist currently have, and what could they develop?
  • how can the clinical pharmacist be supported to meet the practice’s needs?
  • how will the clinical pharmacist’s success in their role be measured to ensure there is a return on investment?

Understanding competency and setting realistic expectations

When recruiting a pharmacist or any other healthcare professional, it is crucial to take stock of what the practice wants to achieve by expanding the MDT and how this is going to impact on staff and, ultimately, on patient care.

In the author’s experience, unless practices have worked with pharmacists before, there can be a misunderstanding about what clinical pharmacists are able to do, and how their skillset is best used. At one end of the spectrum, this can result in the pharmacist becoming a glorified and expensive administrator, and at the other end, expectations can be unrealistic for a new pharmacist and can lead to inadequate supervision. Both ends of the spectrum will ultimately lead to dissatisfaction for both the practice and the pharmacist.

Not all pharmacists will have the same background or post-graduate qualifications, and their previous experience will very much impact on what they can do confidently and competently when they start out in general practice. Using a systematic approach to set up and deliver the pharmacist service will ensure that:

  • elements of the clinical pharmacist’s aptitude and attitude are identified at the interview stage, providing a good understanding of how their capabilities match the requirements of the practice
  • there is clear plan for the clinical pharmacist at the outset.

A robust induction is vital and requires investing time upfront to support the clinical pharmacist so they can be clear about what is expected of them and fully aware of escalation processes. It is advisable to sit down with the clinical pharmacist to discuss the practice needs, what the expectations are of them now and over the next 3 months, and what the practice wants them to achieve in the first year. A practice diagnostic assessment and a competency assessment are excellent tools that can be used to highlight any gaps within the clinical pharmacist’s experience or competence, and will indicate the level of supervision or development required for them to reach the desired outcome. In addition, this assessment will provide a clear focus for the clinical pharmacist too, meaning that all efforts are directed for the benefit of the practice.

Prescriber versus non-prescriber

Pharmacists without a prescribing qualification can still do a great deal to impact on patient care and workload reduction. Just because they cannot prescribe, it does not mean they cannot hold consultations with patients! Non-prescribers, however, will likely need supervision and assistance during patient-facing clinics and will also need most interventions authorised by a GP (as well as the signing of repeat prescriptions). Therefore, the independent prescribing status brings with it a great deal of autonomy and many operational efficiencies so is worth the investment.

If a clinical pharmacist is going to enrol on an independent prescribing course, they will need a GP to support them as their designated medical practitioner. The requirements for each university vary, but the Royal Pharmaceutical Society states that each pharmacist must have documented 90 hours of supervision. A proportion of these hours can be delegated to other members of the practice team, or indeed outside of the practice, e.g. community or secondary care specialists.

If a clinical pharmacist is qualified to prescribe independently, do not assume they can prescribe everything. It is likely that they will have confidence in the clinical area they have chosen to study, but will need to develop their scope to ensure safe prescribing according to the requirements of the practice. Table 1 summarises some of the key tasks that practices can expect prescribing and non-prescribing clinical pharmacists to be competent in performing from the outset. This is not an exhaustive list and will vary according to each individual pharmacist and the needs of individual practices, but it can prove a useful guide when setting expectations.

Table 1: Summary of typical duties for prescriber and non-prescriber clinical pharmacists
Junior and senior pharmacist responsibilities
(non-prescriber or relatively inexperienced at working within GP practice)
Additional senior pharmacist responsibilities
(usually a prescriber)
Likely out of scope (unless indemnity and competency assessed)
QOF=quality outcomes framework; LTC=long-term condition; MDT=multidisciplinary team
  • Clinical medication reviews
  • Polypharmacy reviews
  • Answering medicine queries
  • Medicines reconciliation
  • Supporting incentive schemes
  • Supporting public health campaigns
  • Medicines optimisation
  • Contributing to QOF
  • Clinical audit
  • LTC clinics
  • Streamlining repeat prescribing process
  • Integrating with community and hospital pharmacists
  • Home and care home visits
  • Pathology interpretation
  • Physical assessments (within scope of practice)
  • Immunisations and vaccinations
  • Ownership for medicines management incentive schemes
  • Managing referrals
  • Signing repeat prescriptions
  • Ownership of QOF domains
  • Training & supervision of junior pharmacists/MDT team
  • Medicines management lead
  • Undifferentiated diagnosis
  • Minor/acute illness clinics

What level of supervision is required for clinical pharmacists?

Once expectations and accountabilities are established, it is essential to agree the right level of support and supervision for the clinical pharmacist. In the author’s experience, getting supervision right is essential to ensure the pharmacist excels in their role and feels both confident and safe in the decisions they make.

The practices that generally have better outcomes with their pharmacists are those which provide structured and accessible support. Simple things like having the pharmacist mirror the working pattern of their clinical supervisor or being placed in a room next door or at least nearby, can make a real difference to how the pharmacist works, providing them with assurance that should they need advice, they can access it quickly. It also provides easy opportunity for development, for example, if the GP is reviewing a patient who requires a physical assessment, they can easily access the pharmacist to come and observe or carry out the assessment under supervision. If this cannot be put in place due to capacity reasons, then it is important that the clinical pharmacist has regular contact points with their clinical supervisor—this may be through weekly de-briefs to discuss any patient cases or review note entries. It is also essential that the clinical pharmacist knows who to contact should an emergency arise or if they need urgent advice. Some practices use their on-call GP, or another named GP where appropriate.

The type of supervision will vary depending on the tasks the pharmacist will be performing. It is advisable that practices initially arrange some shared clinics and shadowing—this provides an opportunity for GPs to observe how the pharmacist takes a clinical history and how they conduct a consultation. Supervision will not only help with the pharmacist’s learning and development but will also provide the practice with some insight into their ability and identify knowledge gaps, which will further inform the clinical pharmacist’s development plan and assure the practice that they are safe to conduct patient-facing clinics.

How to measure performance and productivity

Having a pharmacist as part of the MDT is a relatively new concept for most practices, and therefore the practice will likely want to be able to measure the clinical pharmacist’s impact to ensure that they are a beneficial addition to the team, who will ultimately deliver a return on investment.

Performance and productivity can be assessed in several ways:

  • Setting key performance indicators (KPIs): create a list of KPIs specifically related to the desired outcomes for the practice. These may be quantitative (e.g. the number of available GP appointments), or qualitative (e.g. successfully setting up a pharmacist-led asthma clinic). KPIs are useful in that they provide a measure and a focus for both the practice and the clinical pharmacist and can be changed/updated as the clinical pharmacist role develops
  • Patient satisfaction surveys: providing patients with a simple satisfaction survey to complete anonymously after their appointment with the pharmacist can provide invaluable feedback about the impact the pharmacist is having on patient care
  • Staff feedback: tailoring questionnaires to the activities pharmacists have been involved in, and ascertaining how other staff feel after implementation, can prove useful in understanding how much benefit the pharmacist has brought to the practice. For example, asking GPs how much time they were spending on prescription queries before and after the pharmacist started
  • Pharmacist assessment: pharmacists who are enrolled on the Centre for Pharmacy Postgraduate Education national training pathway will have regular assessments as part of their training. For those outside of the pathway, it is essential that practices agree how they will assess pharmacists. This should be a combination of observation, case-based discussions, and reflective practice to provide assurance of their competence.

A case study of a general practice in London, which has employed a pharmacist as part of the NHS England pilot, is provided in Box 1. The practice invested time in developing their pharmacist and had clear expectations and objectives with accessible and frequent supervision. This resulted in the pharmacist upskilling quickly and practising safely, freeing up GP capacity and improving access for patients.

Box 1: Case study of a clinical pharmacist’s impact on a practice in North West London

Practice list size: 10,000

Clinical pharmacist background:

  • community pharmacy background (registered 2013)
  • started as a clinical pharmacist in 2015 outside of the NHS England pilot
  • obtained an independent prescribing qualification in 2016
  • working in general practice 3 days per week as part of the NHS England pilot (2016–present).

Pharmacist activities:

  • 200–250 appointments each month
  • 140 minor illness appointments each month
  • 2 hours per day dedicated to medicines queries.

Pharmacist training, supervision, and development:

  • training—CPPE GP pharmacist training pathway, minor illness diploma (6 months)
  • supervision—open door policy for emergencies/tasks, 1 hour per week catch-up meeting with clinical supervisor
  • development needs—upskill in chronic disease management and some enhanced services.

Successes and challenges:

Successes:

  • valued member of the team
  • developing skill set
  • taking a lead role on some management
  • practice now thinking about needing more pharmacists
  • 2–3 hours of GP prescription admin time saved each day for the practice
  • more cost-effective consultations.

Challenges:

  • understanding competence and safety of pharmacists
  • induction, supervision, and mentoring
  • lack of structure to training.

By effectively planning in this way, there will be clear accountabilities, a development plan, and appropriate supervision in place to accelerate the development and output from the clinical pharmacist, while also providing a safe and open environment for the pharmacist to grow in their role.

Top tips

  1. Ensure the clinical pharmacist has a clear development plan and that they are supported to achieve it. The plan should be based on the practice’s needs and the pharmacist’s training needs. It should consider their scope of competencies, indemnity, and supervision levels. In the early stages it is prudent to ask for evidence of any specific competencies and ensure some oversight/shadowing. Pharmacists are required to maintain up-to-date CPD records and should be able to provide evidence of this if necessary
  2. Support the clinical pharmacist to continue developing their skills—they may need more support initially but will soon be able to work autonomously. Be aware that although it may seem a good idea to hand over all of the practice medicines queries and repeat prescribing to the pharmacist, they will likely tire of doing just this day in and day out. The worst scenario would be one where, having invested time in developing a fantastic clinical pharmacist, a practice finds that they want to leave because they are dissatisfied with their role
  3. Do not reinvent the wheel—although employing and supporting a clinical pharmacist may be new to some, the role is now well established, and no one should be asking the pharmacists to create templates, searches, and audits from scratch. There is now specific training and resources for the clinical pharmacist role (available to both pharmacists and practices), which will accelerate the clinical pharmacist’s effectiveness
  4. Set clear and measurable outcomes using KPIs, patient feedback, staff feedback, and assessments and put the onus on the clinical pharmacist to measure and present these back to the practice at agreed checkpoints; this keeps everyone focused
  5. Embed the clinical pharmacist as a key clinician and part of the MDT; invite them to meetings, ask them to lead the practice prescribing meetings, and give them the opportunity to contribute their skills and expertise.

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.

Shailen Rao, Managing Director of Soar Beyond Ltd

Shailen Rao

Managing Director, Soar Beyond Ltd

Anna Prescott

Clinical Services Manager, Soar Beyond Ltd

References

  1. Mann C, Anderson C, Avery A et al. Clinical pharmacists in general practice: pilot scheme. Independent evaluation report: full report. June 2018. Available at: www.nottingham.ac.uk/pharmacy/documents/generalpracticeyearfwdrev/clinical-pharmacists-in-general-practice-pilot-scheme-full-report.pdf (accessed 2 August 2018).