Dr Michael Holmes and Sarah Woffinden respond to questions on the addition of a pharmacist to the practice team, and discuss the positive impact it has had on both patients and staff alike

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What is the background to Haxby Group Practice?

A Haxby Group is a large GP practice originating in York but now with practices in York and Hull. In total it serves a population of 50,000 patients—33,000 in York and 17,000 in Hull. It has a strong history as a training organisation and continues to provide training for undergraduate medical and nursing students, GP registrars, practice nurses, and is an Advanced Training Practice Hub for North and East Yorkshire and Hull.1

The practice has a thriving apprenticeship scheme for both clinical and non-clinical staff, something we are incredibly proud of. In recent years the practice has become increasingly interested in working more closely with pharmacy and holds shares in four local community pharmacies; this has given a clear focus on the skills that pharmacists have to offer as well as highlighting how GPs and pharmacists can work together to deliver a strong clinical product.

What was the rationale behind adding a pharmacist to the practice team at Haxby Group Practice?

A In 2012, we identified our prescription management system as an area that required improvement. Analysis of our activity showed that a significant amount of GP time was spent on prescription management. As a practice we were also acutely aware of the looming issues with respect to the GP workforce, and the need for primary care to work with other healthcare professionals collaboratively in order to use GP time more efficiently and effectively for the benefit of patients.

Haxby Group is always looking for innovative ways to provide better patient care. Through working with and talking to pharmacists who worked in the community pharmacy attached to the surgery we realised the potential impact that a pharmacist could have working directly in the surgery; their medicines management skills suggested they were well equipped to help address the problems with our prescription management system. Informal discussions between the practice and pharmacists resulted in a better understanding of exactly what they could offer in a primary care context.

How were other stakeholders involved in the process?

A Work to introduce a pharmacist into the practice was initiated by the practice after full consultation with all of the partners, and discussion about the roles with our patient participation group. Subsequently, once the systems had been established and the pharmacist’s role was embedded in the practice, we were able to share our learning with other practices locally and with Health Education Yorkshire and the Humber.2 At the time there was no additional NHS funding available to support this venture; we funded it ourselves and we have certainly received return on that investment.

What are the main functions of the practice pharmacist?

The two main overarching principles of the pharmacist’s role are to deliver prompt and safe services for patients, and to work within a team to ensure that all professionals are maximising their input and availability for patients.

The prescription management role comprises:

  • reauthorising prescriptions
  • dealing with a range of prescription queries
  • carrying out:
    • prescribing audits
    • medication switches and alternatives
  • amending prescriptions following hospital discharge or outpatient appointments
  • synchronising prescriptions
  • suggesting removal of prescribed items that are no longer required
  • commenting on polypharmacy in the elderly and patients with complex needs
  • management of Medicines and Healthcare products Regulatory Agency issues.3

At this stage treating patients with minor ailments has not been part of the practice pharmacist’s role. Up to now, seeing patients clinically is something that has been delivered by community pharmacists and we are working directly with our local pharmacy to explore this aspect further. Our aim is to develop the practice pharmacist’s role to include clinical elements; this may involve them in managing acute presentations and monitoring long-term conditions. We are currently developing the potential for the practice pharmacist to be involved with the monitoring and management of hypertension.

The practice pharmacist has worked with our dispensing service to carry out Dispensing Reviews of the Use of Medicines (DRUMs) and we are exploring the development of a domiciliary medicines use review service in collaboration with community pharmacy colleagues. We have also been running a small project funded by our local CCG where our practice pharmacist has worked with GPs as part of a multidisciplinary team to look at prescribing for our elderly patients with a view to making sure we are prescribing safely, appropriately, and that patients are using their medication correctly. We are now considering the potential for a larger service delivering Domiciliary Medicines Use Reviews.4

How was the workload transferred from the practice GPs and nurses to the pharmacist?

A As with most new ventures, the introduction of a practice pharmacist required planning and a very close eye on governance to ensure patient safety. The practice pharmacist took on the role of prescription management; this worked very well and was implemented quickly. The pharmacist worked closely with one of the GPs and within a short period the majority of prescriptions were being managed without GP involvement. A multiprofessional approach to developing in-house protocols for reauthorising prescriptions was adopted and it soon became clear where the practice pharmacist could add the most value.

Our hope is that the practice pharmacist will become more involved with chronic disease management and become a valuable resource not just for the practice, but for the wider healthcare community. Her involvement in domiciliary reviews in the community has enabled a focus on reducing medicines wastage and this has proved very promising.

As more GP time is made available, other patient-centred services have also been improved or developed. There has been a focus on the management of acutely ill patients, ensuring access to a GP on the same day, as well as the introduction of longer GP appointments (up to 30 minutes) for patients with more complex needs.

Was the role of the practice pharmacist clearly defined at the outset or has it developed through ‘trial and error’?

It has been more a case of ‘trial and evolve’ based on an understanding of the skillset of the pharmacist. The cornerstone of medication and prescription management was clearly defined as the pharmacist’s role, and this has evolved through a collaborative approach. The key has been remaining positive and having belief in the fact that ‘collaborative medicine’ is the future of primary care and that the real beneficiaries will ultimately be the patients.

How is the practice pharmacist involved in training others?

A As time has progressed, the pharmacist has become more involved in teaching GP registrars, providing an invaluable resource for qualified GPs, and has also attended events involving patients. Haxby Group Practice is one of Health Education Yorkshire and the Humber’s Advanced Training Practice Hubs and we have placed training and education at the heart of our ethos, so having our practice pharmacist delivering teaching and training was a natural progression and has been a resounding success.

We have encouraged our practice pharmacist to complete a Postgraduate Certificate in Education and she is now involved in teaching medical students and student nurses through the delivery of Interprofessional Learning Sessions. Furthermore we understand that we will be hosting undergraduate pharmacy students in the near future.

What financial implications are associated with employing a practice pharmacist?

While a number of funding schemes for practice pharmacists are now becoming available (see Box 1, below), at Haxby we employed our pharmacist without any additional funding, having recognised the potential benefits for our patients and our workload.

The reality is that the return on investment here is excellent if we consider the benefits in terms of available GP time alone. Our analysis showed that around 60 hours of GP time were spent per week reauthorising prescriptions, a task that is now performed in 35 hours of pharmacist time, as there is an uninterrupted professional focus and significantly improved efficiency.

Of course the actual benefits go beyond time saved, but are much more difficult to measure; the development of a multi-professional team with a focus on delivering efficient care for patients has been and remains the overarching goal, and one which we feel we are a step closer to achieving. We welcome the introduction of funding for practice pharmacists and hope this will encourage more practices to embrace the collaborative benefits of working with pharmacists.

What was the impact of the initiative on patients and the rest of the practice team?

A We feel the primary beneficiaries have been our patients, but this has been closely followed by GPs in terms of the available time they can now devote directly to patient care, particularly for the patients with more complex needs who form an ever increasing part of the GP workload. For a breakdown of the impact on different patient groups, and members of the practice staff, see Box 2, below.

Box 2: Impact of adding a pharmacist to the practice team on patients, practice staff, and the wider healthcare community

Benefits for patients

  • Reduced prescription-processing time
  • Repeat medication is synchronised so reauthorisation is required less often, again reducing potential delays
  • Repeat lists are kept up to date with unused items removed
  • Patients have access to the pharmacist for medication queries
  • Prescription problems are highlighted earlier, resulting in better care
  • New medication is added to the repeat scripts quickly following hospital discharge—this saves confusion, increases medication safety, and optimises treatment
  • Availability of Patient Education events, including:
    • Practice Diabetes Group—pharmacist talks to patients about medication that they may be prescribed in addition to their diabetic medication (e.g. aspirin, statins, antihypertensives), what they are for, and why they are important
    • one-to-one medication education meetings as part of the DRUM
  • Increased same-day access to GPs.

Benefits for GPs

  • A significant amount of GP time has been made available
  • GPs are able focus on more appropriate work (e.g. patients with complex needs, patients with multimorbidity)
  • There is a greater alignment with local prescribing guidance
  • The practice pharmacist is also able to:
    • process and assess all prescription requests on behalf of GPs
    • highlight high-risk prescribing, e.g. opiate use
    • run chronic disease management clinics
    • contribute to MDT assessment of ‘at risk’ patients
    • provide a medication advice service to GPs
    • complete DRUMs for dispensing patients
    • identify issues and develop a close working relationship with GPs to ensure patients are referred back to the GP when appropriate.

Benefits for the reception team

  • Access to pharmacists for medication queries
  • Pharmacist-delivered training related to prescription management
  • Fewer prescription queries from patients.

Benefits for nurses

  • Increased pharmacist availability for medication advice
  • Pharmacist-delivered training for student nurses, practice nurses, and those on the prescribing course
  • Pharmacists are able to review clinic templates as new guidance emerges.

Benefits for GP Registrars and Advanced Nurse Practitioners

  • Access to the practice pharmacist for medication and prescribing advice
  • Pharmacist-delivered training.

Benefits for medical students

  • Individual tutorials covering pharmacology and prescribing.

Benefits for community pharmacies

  • Improved communication
  • Improved pharmacy–practice relationship
  • Proactive management of medicine availability
  • Efficient management of medication changes for ‘tray’ patients.

Benefits for care homes

  • Repeat prescriptions are dealt with more quickly, and reviewed regularly
  • Reduction in polypharmacy in elderly patients
  • Improved patient care
  • Practice pharmacist is able to provide a more efficient response.

DRUM=dispensing review of use of medicines; MDT=multidisciplinary team

What does the future hold for Haxby Group Practice?

Our plan is to build on the service with the introduction of further pharmacists to serve all our patients across all of our practices, while at the same time supporting the introduction of training, development, and mentorship of primary care pharmacists wherever possible. We are currently developing strong relationships with other practices and hope to work with our new partners to introduce pharmacists alongside GPs at every opportunity. In my role as RCGP Clinical Lead for their Supporting Federations Programme I am beginning to see how working at scale can help bring about innovative workforce solutions. Perhaps the vision should be the introduction of a vocational training scheme for newly qualified pharmacists that mirrors the scheme for GP registrars. In addition we are exploring the introduction of new skillsets alongside the pharmacist such as pharmacy technicians to broaden the role of the pharmacy team to offer a wider range of services.

We also feel we are well placed to share our experience and developing expertise in this field with other organisations and would be very happy to do this should we be asked. We have shared our learning with Health Education Yorkshire and The Humber and would be very supportive of the development of clear career pathways for pharmacists to enter primary care after training.

We are beginning to employ other professionals to expand our ‘collaborative medicine’ approach—for instance we are developing an acute care team, which involves paramedics and nurse practitioners, and our hope would be that pharmacists can also play an important role here. As we have mentioned, education is very important to us and we are going to be accommodating pre-registration pharmacist placements in the near future.

What would be your advice for GP practices looking to implement a similar initiative in their locality?

The first message is that our pharmacist has become a significant member of our practice team. One of the key issues here is to develop your own protocols and ways of working with the pharmacist—ensure you are comfortable with the governance. As with GPs, different pharmacists have different skillsets so it is important to have a clear understanding of their capabilities so that you can maximise their potential.

As ever, communication between everyone involved with the process is vital and of course this includes the patients. Overall, we have found this collaboration extremely rewarding. It has had a huge impact on the working lives of our GPs and we would not want to go back to working without a practice pharmacist and, perhaps more importantly, we are sure our patients wouldn’t either.

References

  1. NHS Health Education Yorkshire and the Humber. Advanced training practice: information pack. Available at: yh.hee.nhs.uk/files/2013/07/ATP-Information-Pack2.pdf
  2. NHS Health Education Yorkshire and the Humber website. Available at: yh.hee.nhs.uk (accessed 19 August 2015).
  3. Medicines and Healthcare products Regulatory Agency website. Available at: www.gov.uk/government/organisations/medicines-and-healthcare-products-regulatory-agency (accessed 20 August 2015).
  4. Pharmaceutical Services Negotiating Committee website. Services database: domiciliary medicines use reviews. Available at: psnc.org.uk/?our-services=domiciliary-medicine-use-reviews (accessed 3 September 2015).