George Brooks and Dr Honor Merriman discuss how integrating pharmacists into the practice team and working closely with community pharmacists can improve prescribing in primary care

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Read this article to learn more about:

  • how GPs and pharmacists can work together to support improvements in patient care
  • pharmacist-led prescribing support
  • examples of cost-saving prescribing switches.

Key points

GP commissioning messages

General practitioners are required to prescribe daily in response to both face-to-face consultations and requests from patients to issue repeat scripts. The General Medical Council (GMC) has issued guidance on Good practice in prescribing and managing medicines and devices to ensure the safe prescribing of medicines.1 Improving the quality of prescribing in primary care has the potential to improve patient safety, increase medicines adherence, and reduce prescribing costs.

The GMC advises that GPs should work together with pharmacists in order to attain professional standards. This is in line with the view of the Royal College of General Practitioners (RCGP) for the future of general practice, put forward in their guidance, The 2022GP.2

The future of general practice

The RCGP predicts that in the future, successful general practices will be working with pharmacists either within their practice teams, or in partnership with community pharmacists. This view is supported by several others, including The King's Fund in its publication, Securing the future of general practice: new models of primary care.3 A recent report commissioned by the Royal Pharmaceutical Society (RPS) reinforced the idea of pharmacists adopting roles in patient care and increasing their involvement with GP Federations,4 as also envisaged in the NHS Five year forward view.5 In March 2015, the RCGP and RPS released a joint statement outlining the vision of pharmacists working within GP practices. 6

For decades, general practices have relied on the practice team of GPs and nurses working together to deliver good patient care; working with pharmacists would be a logical next step. Practices are already employing pharmacists, some of whom have qualifications that allow them to prescribe. Pharmacists who are trained to prescribe can be employed by general practices to play a key role in the review of patients with long-term conditions, for example, asthma. The General Practice Foundation, 7 provided by the RCGP, supports the general practice team of nurses, physician assistants, and practice managers in their continuous professional development. Extending this resource to include pharmacists would be a natural development for the future of general practice.

Community pharmacy has much to offer primary practice

Pharmacists are already engaging with patients through Medicines Use Reviews (MURs). These are structured reviews that aim to establish a patient's understanding and use of their medication, and identify any side-effects or barriers to compliance. Since 2011, community pharmacies have provided additional support to patients starting on certain new medications (e.g. nonsteroidal anti-inflammatory drugs, inhalers, antihypertensives) under the New Medicines Service (NMS). Both of these centrally funded services see pharmacists supporting the care of patients, often including those with multiple conditions and extensive repeat medications. The Pharmaceutical Services Negotiating Committee (PSNC) has published a briefing for GP practices on MURs and the NMS.8

Advanced Services such as MURs and NMS earn the pharmacy a guaranteed fixed fee-for-service, up to an annual cap (currently 400 MURs9 and 0.5% of prescription volume for NMS10). Many pharmacies do not routinely reach these limits and so would welcome an opportunity to increase service delivery. As such, pharmacy advanced services can be a useful adjunct tool for primary care physicians.

Asthma care

Pharmacists routinely review patients' asthma symptoms (often based on the Royal College of Physicians 'three questions', as well as teaching or optimising their inhaler technique.11 Optimising inhaler technique can lead to a dramatic increase in drug delivery and subsequent physiological response. Even patients with good inhaler technique develop 'bad habits' and can benefit from review. Patients first presenting with suspected asthma and those with poorly controlled asthma should receive training in the use of their inhaler, and have their inhaler technique assessed.12 This could be performed in a community pharmacy where new patients are referred to the NMS, and current patients are invited to undergo a MUR to assess inhaler technique. Often an improvement in inhaler technique can remove the need for an increase in dose, thus controlling prescribing costs and minimising dose-related side-effects. A number of projects assessing pharmacy management of asthma have repeatedly demonstrated the positive impact of pharmacist intervention including improved medication adherence, reduced short-acting β2 agonist prescribing, fewer asthma-related GP appointments, and reduced acute admissions.13

Blood pressure monitoring

Pharmacies routinely offer blood pressure measurement, providing advice and referring patients when necessary. This expertise could be combined with the NMS and integrated into a practice's hypertension treatment pathway. Patients are recruited into the NMS at the point of dispensing and initially contacted on day 7–14 to assess response, side-effects, and compliance. A further follow up occurs 14–21 days after the initial intervention.9 Patients could be directed to the NMS and asked to visit the pharmacy for blood pressure monitoring. The prescription could include criteria for referral back to the GP (e.g. 'blood pressure persistently over 135/85 mmHg'), which may lead to a reduction in the number of GP referrals. Blood pressure readings could be included with subsequent repeat medication requests. Such a system has the potential to both increase appointment availability and enhance the patient–pharmacist relationship.

Pharmacist-led prescribing support in the practice

Pharmacists can synchronise patients' repeat medications, aligning the course length and repeat cycle of all medications, simplifying the repeat process for patients, prescription clerks, and authorising GPs alike. Patients with synchronised medications can then be considered for repeat dispensing. Repeat dispensing is a controversial topic and will not be discussed in this article, but a strong GP practice–pharmacy relationship is fundamental to its successful implementation.

Prescribing has to be cost-effective and this is another facet of safety. Reducing the costs of prescribed items must be seen in the context of improving the appropriate choice of items for patients. Many patients have co-morbidities and the choice of medication must take this into consideration. Working with a community pharmacist who can provide professional expertise adds to the quality improvement process. Those considering a programme of medicines optimisation should review recent NICE Guideline 5 on Medicines optimisation—the safe and effective use of medicines to enable the best possible outcomes, see www.nice.org.uk/guidance/ng514 (a summary of the guideline can be found on the Guidelines website).

Category M medicines

Pharmacists are acutely aware of the variable cost of medication. Community pharmacy continues to be funded, in part, through retained profit margins from the dispensing of approximately 500 common primary care drugs—the so-called 'Category M' medicines.15 For the 2014/15 financial year, the PSNC Community Pharmacy Funding Settlement set the retained margin element for Category M medicines at £800 million. The Drug Tariff price for Category M medicines is calculated from wholesaler and manufacturer price lists to include this margin and is adjusted regularly, based on historic and predicted dispensing data, to ensure the agreed sum is delivered but not exceeded. This mechanism encourages pharmacies to seek the best value generics, driving down the overall cost of generic medications.16

The recent rise in Category M prices has increased pressure on practice prescribing budgets, making cost-conscious prescribing more important than ever. It can be tempting to reduce prescribing costs by switching to certain branded medicines or 'branded generics' with a lower list price than the equivalent Category M generic drug. Such practice is strongly discouraged by the PSNC.17 While generic to brand switching may garner short-term savings, it can backfire for two key reasons:

  • manufacturers of branded drugs and branded generics struggle to sustain the attractive list price, leading to shortages and/or price hikes
  • branded products do not contribute to the Category M retained profit mechanism; Category M profits are guaranteed across the whole category, so disruptive changes that reduce the dispensing volume of one Category M drug (with a corresponding reduction in the retained profit margin) must be compensated for by an increase in the cost of other drugs in the category in order to meet the agreed £800 million sum.

What may seem like an attractive switch initially may ultimately be neither cost-effective nor serve broader NHS interests over the long term. Your local medicines management team will be able to provide advice on appropriate cost-saving switches.

Cost-saving switches

There remains substantial potential for prescribing savings that can enhance patient care. The authors of this article implemented a number of cost-saving prescribing changes with a view to reducing annual prescribing costs and enhancing pharmaceutical care for patients. Some of the changes made are summarised in Table 1, below. Pricing Data was collected from Drug Tariff, April 2015.18 The changes outlined below are a selection of the cost-saving switches implemented following suggestions from the local CCG medicines management team. When deciding which switches to implement, those that could improve patient care and experience while also producing cost savings were chosen. When implementing these switches, patients were more receptive to medication changes when they were explained (either by letter or telephone) in terms of the therapeutic/clinical benefit rather than cost alone. In a practice with a list of approximately 14,000 patients, each of these switches affected between five and 20 patients. These switches produced expected annual prescribing savings in excess of £7000.

Conclusion

The pressure on primary care is already great and only expected to increase. In such testing times it is essential that we maximise the value of the care we already provide and develop innovative ways of delivering care in the future. Pharmacists' skills and expertise are a good fit for the primary care model and their greater involvement could expand and enhance the capacity of practices to deliver care to an ever-expanding patient base. Those interested in pursuing these opportunities should consider contacting their local pharmacy to explore the potential for collaboration.

Table 1: Examples of cost-saving prescribing changes
Current treatmentPotential switchSuitable individualsRationale behind the switchPotential cost saving per patient
FormDrug tariff price (p) / unitsCost over 28 days (£) / unitsAnnual savings (13 x 28 days)
calcium and vitamin D tablets colecalciferol/calcium carbonate tablets patients who require calcium and vitamin D supplementation who cannot tolerate chewable tablets
  • calcium and ergocalciferol tablets provide 400 unit vitamin D but only around 100 mg calcium
  • increase calcium or give vitamin D only: options include colecalciferol 200 unit/calcium carbonate 750 mg tablets and colecalciferol 800 unit capsules.
calcium and ergocalciferol tablets 1311p / 28 £13.11 / 28 N/A
colecalciferol 200 unit / calcium carbonate 750 mg tablets 365p / 112 £1.33 / 56 £153.14
colecalciferol 800 unit capsules 360p / 30 £3.36 / 28 £126.75
omega-3 fatty acid compounds stop prescribing patients with CVD using omega-3 fatty acid compounds for lipid modification
  • NICE Clinical Guideline 181 no longer recommends omega-3 fatty acid compounds for the prevention of CVD.19 Patients who want to continue can purchase omega-3 fatty acid compounds from pharmacies (retail price varies; approx. £25/pack).
omega-3 fatty acid compounds (e.g. eicosapentaenoic acid 460 mg /docosahexaenoic acid 380 mg capsules 1424p /28 £14.24 / 28 N/A
stop treamtment N/A N/A £185.12
omeprazole 40 mg gastro-resistant capsules omeprazole 20 mg gastro-resistant capsules patients regularly prescribed 40 mg omeprazole daily
  • omeprazole 40 mg capsules come in pack sizes of seven, which are bulky and inconvenient. Tablets/dispersible forms are also expensive
  • 20 mg capsules allow patients to vary dose depending on symptoms (1 or 2 capsules daily), and fit into medical storage devices more easily
  • review opportunistically.
omeprazole 40 mg gasro-resistant capsules 109p / 7 £4.36 / 28 N/A
omeprazole 20 mg gastro-resistant capsules 123p / 28 £2.46 / 56 £24.70
paracetamol—soluble tablets paracetamol—tablets patients with hypertension and/or heart failure without dysphagia (e.g. already prescribed other non-soluble tablets/capsules)
  • dose of 8 tablets per day can contain 110-170 mmol sodium, which exceeds the recommended daily sodium intake of 100 mmol (refer to the UK Medicines Information summary of high sodium preparations).20
paracetamol 500 mg soluble tablets 596p / 100 £13.35 / 224 N/A
paracetamol 500 mg tablets 300p / 100 £6.72 / 224 £86.19
tolterodine 4 mg MR capsules tolterodine 2 mg tablets patients who were initiated on 4 mg MR capsules without trying immediate-release tablets
  • tolterodine 2 mg is indicated as the first-line treatment21
  • twice-daily administration allows for flexible dose controlled by the patient, depending on their lifestyle, symptoms, and need.
tolterodine 4 mg MR capsule 2578p / 28 £25.78 / 28 N/A
tolterodine 2 mg tablets 278p / 56 £2.78 / 56 £299.00
  • CVD=cardiovascular disease; MR=modified release
  • Drug prices correct at 13 April 2015
  • Click here to download the full size table in a new tab.

Key points

  • Pharmacists and GP practices need to work together to effect safe and cost-effective prescribing. This can be achieved either through the practice employing a pharmacist directly, or through partnerships with local pharmacists working in the community. Like nurse colleagues, pharmacists can become independent prescribers
  • Safer prescribing in line with latest guidance may also be more cost effective and working with a local pharmacist can ensure that changes are made that benefit both the patient and the health economy
  • Local medicines management teams and CCG pharmacist resources can help practices identify and implement cost-savings and medicines optimisation
  • Pharmacists can provide flu immunisations, blood-pressure measurements, asthma reviews, and medicines reviews, and practices should consider how to make best use of these services
  • Community pharmacies could provide additional capacity in managing patients whose long-term conditions are well-controlled, particularly for patients who find it difficult to attend clinics during work hours
  • Under the NMS, pharmacies support patients starting certain classes of medication soon after initiation. Patients can easily be referred to a local pharmacy for the service. Practices should consider integrating an NMS into certain treatment pathways (e.g. hypertension).

NMS=New Medicines Service

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GP commissioning messages

written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead

  • Although pharmacists have always held a traditional role in supporting GPs in the care of patients through dispensing roles and medicines optimisation teams, there is increasing emphasis on integrating them into general practices
  • The current naked truth is that there is a severe shortage of GPs and practice nurses yet there is an excess of trained pharmacists, so it is logical and pragmatic now to look to extending the role of pharmacists beyond their traditional dispensing role
  • Pharmacists can add value to patient care through traditional medicines optimisation but also through acquiring an extended suite of clinical skills to support and substitute some activity previously performed by GPs
    • this will require some post-graduate training to gain competence in prescribing, minor illness management, and long term condition care which is probably unreasonable to expect general practices to undertake unfunded
  • CCGs working with local deaneries, NHS England, and health education England should:
    • review their primary care workforce plans and see what role there would be for pharmacists
    • commission local programmes to ensure this abundant resource can help adapt to become an integral part of general practice as well as community pharmacy
  • Dispensing general practices should consider employing a pharmacist to oversee their dispensing practice but also enrich their clinical team.

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References

  1. General Medical Council. Good practice in prescribing and managing medicines and devices. GMC, 2013. Available at: www.gmc-uk.org/ Prescribing_guidance.pdf_59055247.pdf
  2. Royal College of General Practitioners. The 2022 GP. RCGP, 2013. Available at: www.rcgp.org.uk/campaign-home/~/media/files/policy/a-z-policy/the-2022-gp-a-vision-for-general-practice-in-the-future-nhs.ashx
  3. Nuffield Trust and The King's Fund. Securing the future of general practice—new models of primary care. Nuffield Trust, 2013. Available at:www.nuffieldtrust.org.uk/sites/files/nuffield/ publication/130718_securing_the_future_ summary_0.pdf
  4. Royal Pharmaceutical Society. Now more than ever: why pharmacy needs to act. Nuffield Trust, 2014. Available at: www.nuffieldtrust.org.uk/ publications/now-more-ever-pharmacy
  5. NHS England. Five year forward view. NHS England, 2014. Available at: www.england.nhs. uk/wp-content/uploads/2014/10/5yfv-web.pdf
  6. Royal Pharmaceutical Society, Royal College of General Practitioners. RCGP and RPS policy statement on GP practice based pharmacists. February 2015. Available at: www.rpharms.com/promoting-pharmacy-pdfs/rcgp-joint-statement-for-pharmacists-in-gp-surgeries-version-2.pdf
  7. Royal College of General Practitioners. The general practice foundation. Available at: www.rcgp.org.uk/membership/practice-team-resources/join-general-practice-foundation.aspx
  8. Pharmaceutical Services Negotiating Committee. NHS community pharmacy advanced services—briefing for GP practices. PSNC, 2013. Available at: psnc.org.uk/wp-content/uploads/2013/07/Advanced-services-briefing-for-GPs-Aug-2013.pdf
  9. Pharmaceutical Services Negotiating Committee. Medicines use review and prescription intervention service. August 2013. Available at: psnc.org.uk/wp-content/ uploads/2013/06/MUR-service-spec-Aug- 2013-changes_FINAL.pdf
  10. Pharmaceutical Services Negotiating Committee, NHS Employers. New Medicine Service Guidance. December 2013. Available at:www.nhsemployers.org/~/media/Employers/ Publications/nms-guidance-271213.pdf
  11. Royal College of Physicians website. Measuring clinical outcome in asthma. www.rcplondon.ac.uk/publications/measuring-clinical-outcome-asthma (accessed 7 April 2015)
  12. British Thoracic Society/Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. SIGN 141. Edinburgh: 2014. Available at: www.sign. ac.uk/pdf/SIGN141.pdf
  13. Murphy A. Make asthma SIMPLE for your patients. The Pharmaceutical Journal, 2014. Available at: www.pharmaceutical-journal. com/news-and-analysis/feature/make-asthmasimple-for-your-patients/11138140.article (accessed 7 April 2015)
  14. NICE. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. NICE Guideline 5. NICE, 2015. Available at: www.nice.org.uk/guidance/ng5
  15. NHS Business Services Authority. Category M prices. Available at: www.nhsbsa.nhs.uk/PrescriptionServices/1821.aspx
  16. Pharmaceutical Services Negotiating Committee. Retained Margin (Category M). Available at: psnc.org.uk/fundingand- statistics/funding-distribution/ retained-margin-category-m/
  17. Pharmaceutical Services Negotiating Committee. Branded generics. Available at: psnc.org.uk/funding-and-statistics/ funding-distribution/branded-generics/
  18. NHS Business Services Authority website.Electronic drug tariff. www.ppa.org.uk/edt/April_2015_v2/mindex.htm (accessed 14 April 2015)
  19. NICE. Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. Clinical Guideline 181. NICE, 2014. Available at: www.nice.org.uk/guidance/CG181
  20. UKMI. What is the sodium content of medicines? Available at: www.evidence.nhs. uk/document?ci=http%3A%2F%2Fwww. medicinesresources.nhs.uk%2FGetDocument. aspx%3FpageId%3D504083%3Ffromsource% 3Dnelm&q=%22sodium%20content%22&Re turnUrl=%2Fsearch%3Fq%3D%2522sodium% 2Bcontent%2522
  21. NICE. Urinary incontinence: the management of urinary incontinence in women. Clinical Guideline 171. NICE, 2013. Available at:www.nice.org.uk/guidance/CG171