Shailen Rao and Anjna Sharma discuss the important role of practice-based clinical pharmacists in primary care networks as defined by the new GP contract
Read this article to learn more about:
- the growing importance of clinical pharmacists in the primary care workforce
- the challenges some practices and primary care networks have faced in embedding and supporting clinical pharmacists
- how best to support and accelerate clinical pharmacist development and competence safely.
This article has been developed in association with Soar Beyond Ltd.
The new title of ‘clinical pharmacist’ was introduced in 2015 as part of an NHS pilot to address the scarcity of GPs and nurses at a time when there was an oversupply of qualified pharmacists (Box 1).1 The pilot was well received; the greatest testament being that NHS England now funds 100% of the clinical pharmacist costs (up to £55,670) if employed by a primary care network (PCN) through the Additional Roles Reimbursement Scheme.2
Box 1: General practice clinical pharmacist timeline
- Launch of pilot Clinical pharmacists in general practice scheme1
- Tiered pump-priming funding, which resulted in the practice taking on 100% of employment costs by year 41
- 490 pharmacists (>450 FTEs) across 658 GP practices1
- Uptake of GP clinical pharmacists by NHS sites was inconsistent mainly because of the bidding model by NHS England, which required practices to come together to share the role at one pharmacist per 15,000 patients
- An independent evaluation of the service concluded: ‘Clinical pharmacists have made a unique and valuable contribution to the primary care skill mix. Pharmacists contribute significantly to patient safety, bring medicines and prescribing expertise, support with prescribing tasks, support for patients with long term conditions including support for healthy lifestyles. They have improved medication knowledge in the wider clinical team leading to the prospect of overall improvements in care related to medicines.’3
- January: 70% funding for clinical pharmacists announced in 5-year framework for GP contract reform4
- April: Clinical pharmacists in general practice scheme closes1
- July: 70% funding starts1
- February: 100% funding confirmed in update to the GP contract agreement2
- Concerns raised as to the supply and retention of clinical pharmacists, and impact on the pharmacist workforce
- Anticipated clinical pharmacist workforce of up to 7500;5 5–7 per PCN working as key part of the multidisciplinary team.4
FTEs=full-time equivalents; PCN=primary care network
Impact of new GP contract on pharmacy workforce
The vision articulated in the NHS long term plan is that every PCN will have a workforce of clinical pharmacists; by 2024, PCNs should have approximately 5–7 full-time equivalents—this would equate to a new workforce of up to 7500 clinical pharmacists in the next 4 years.4,5
Pharmacy technicians will also be funded by NHS England (up to £35,389), with PCNs expected to recruit one additional pharmacy technician for 2020/21 and 2021/22 (or two in PCNs with a population of over 100,000 patients); more can be recruited where there are not local supply constraints.2
Should the opportunity arise, pharmacists could also become partners in practices supported by a payment of £20,000 and a £3000 business training allowance. This is based on a full-time role (37.5 hours) and is initially a loan, which NHS England envisages will automatically convert to a permanent payment. Full details of the scheme are yet to be announced.2
These recruitment and retention measures signify the value and importance of the role of the clinical pharmacist and the shift towards a primary care model that is less dependent on GPs.
Importance of clinical pharmacists to PCNs
An independent evaluation of the pilot programme showed that clinical pharmacists had increased capacity in practices and brought a ‘unique and valuable contribution’ to the skill mix in primary care.3
A draft outline of service specifications for the network contract for direct enhanced services was published in December 2019, for consultation.6 GPs and staff from PCNs raised concerns about the prescriptive nature of the direct enhanced service, and that practice-based pharmacists should not be overburdened with challenging targets on delivering specified numbers of structured medication reviews.7,8 After the consultation, the BMA negotiated concessions on these demands. Although structured medication reviews are within the skillset of pharmacists, this backlash highlighted GPs’ desire to use pharmacists to release primary care workforce and capacity.
Local enhanced services and local incentive schemes can also be supported by PCN pharmacists, as can the newly introduced investment and impact fund.2 The investment and impact fund will be a points-based system similar to the quality and outcomes framework, with an allocation of funds for achieving points related to influenza vaccinations, patients on the learning disability register receiving health checks, social prescribing referrals, gastro-protective prescribing, metered dose inhaler use, and spending on medicines that should not routinely be prescribed in primary care. Pharmacists have the skills and expertise to support these services.
Box 2 outlines some key points for PCNs to consider when employing a clinical pharmacist.
Box 2: Points for primary care networks to consider when employing a clinical pharmacist
- Know what you want from your practice pharmacist and what is realistic now and in the near to mid-term future
- Align your pharmacist’s development plan to address your workload and capacity issues by being clear about success metrics
- Understand the unique skills and resources the pharmacist brings—they are neither a cheap doctor nor an expensive nurse
- It is worth investing in the right level of pharmacist and right support to set your pharmacist up for success. If in doubt, seek external expertise or share best practice from fellow primary care networks.
Challenges in deploying clinical pharmacists
Full funding poses its own challenges, however. The pharmacy workforce is facing a recruitment and retention crisis.8 Concerns have also been raised by the Medical Director of Primary Care for NHS England and Improvement, Nikki Kanani, that there are not enough pharmacists working at the level required of a PCN pharmacist.9 Furthermore, issues have been raised by one of the main pharmacy insurers about clinical pharmacists in GP surgeries working outside of their areas of competence.10
There are several potential issues with the employment of clinical pharmacists, for example:
- an undersupply of suitably experienced pharmacists, leading to a highly competitive market
- poor retention of existing clinical pharmacists, despite training and support
- recruitment of inadequately trained pharmacists
- practice staff not knowing how to assess competency and how to support or supervise pharmacists, resulting in pharmacists conducting work outside of their scope of competence
- practice staff feeling that they are spending too much time supporting pharmacists
- pharmacists being used to deal with clinical administration instead of maximising their clinical and patient-facing skills.
An independent review of the pilot scheme highlighted that interprofessional trust should be developed by publicising competencies for the clinical pharmacist role to aid development and progression.3 However, a national list of competencies has not been published by NHS England to support the new recruitment drive.
With so many new professionals entering general practice, the clinical pharmacist is one of the more ‘established’ roles compared with the social prescriber, physician associate, and mental health worker, so it can be easy to assume that the pharmacist requires less support and intervention. The independent review of the pilot scheme highlighted that GP expectations of the clinical pharmacist role do need to be managed.3 With so many primary care healthcare professionals advocating the positive impact that the clinical pharmacist has had on workload, safety, and patient care, it can be easy to expect too much too soon and to expect activities to be undertaken that are beyond the pharmacist’s safe scope of competence. It is imperative, therefore, that practices and PCNs dedicate the time to recruit and support the right pharmacist according to the needs, priorities, capability, and capacity of the practice and the patient population.
Providing structured support for practice-based pharmacists
Soar Beyond has developed some competencies and methodology for structured support to help the NHS to develop clinical pharmacists at a practice, PCN, or wider-scale level.
This uses the SMART (standardise and mobilise, accelerate, resources, and tools) online platform, which is designed to help with the quick deployment of clinical pharmacists to GP practices, and to develop the skills and the services they can offer in line with the practice’s needs. This is supported with an interactive tool (where pharmacists map their skillset against pre-defined competencies) and the ability to report key performance indicators (KPIs). Box 3 outlines how practices can use SMART to help support pharmacists, and the case study in Box 4 demonstrates the SMART methodology in action.
The SMART platform aims to support PCNs, GPs, and pharmacists to:
- help the pharmacist and practice identify individualised development needs when the pharmacist is starting out
- ensure the practice is supporting and supervising the pharmacist in the least time-consuming and most impactful way
- provide the pharmacist with efficient tools and resources, such as long-term condition searches, consultation templates, audits for EMIS and SystmOne, and repeat prescribing toolkits
- demonstrate the pharmacist’s achievements by sharing KPIs that matter to the practice and directed enhanced service delivery.
Box 3: Advice to practices on how to work SMART when taking on clinical pharmacists
SM: Set up and mobilise your clinical pharmacist service
- Consider expectations
- Consider skills required
- Consider appropriate supervision and support
A: Accelerate your service
- Visibility and tracking of KPIs and impact on workload and patient care
- Measurement of baseline and growth in competencies
- Development plan in line with practice and PCN requirements
- Provide appropriate training and supervision to develop pharmacist
RT: Resources and tools
- Access to quality-assured resources and tools to aid learning and support implementation of pharmacist-led services in the GP practice.
KPI=key performance indicator; PCN=primary care network
Box 4: Case study
Three practices in Didcot joined to form Didcot Primary Care Network with a patient population of over 43,000. Despite the practices being local to each other, each practice had different population needs. Although they had good informal relationships, they had no previous experience of working together in an organised way.
The practices all had:
- similar issues regarding workload and capacity
- a good mix of healthcare professionals and a desire to work closely to make the PCN structure successful for their staff and patients
- a clear rationale for investing in a pharmacist with the funding available; however,
- none of the practices had any previous experience of working with a pharmacist other than CCG practice-based pharmacists
- there were concerns that the PCN’s lack of experience and knowledge of background, skills, and training of a clinical pharmacist could lead to common pitfalls they were hearing from other PCNs and they didn’t want to recruit the wrong candidate for their PCN needs.
The PCN needed to recruit and employ an effective pharmacist who could hit the ground running and start prescribing, running medication reviews, and delivering the income generation and clinical requirements of the directed enhanced service in an equitable way across the three practices. PCN staff sought external expertise from Soar Beyond, to accelerate the process and guide them.
Soar Beyond ran a facilitated diagnostic session in July 2019 with participation across the three practices. This session helped staff to:
- understand what the practice pharmacist can do and how they would add value
- collate the needs of the individual and collective practices, and manage practice expectations
- identify the specific skillset of the clinical pharmacist they wanted to recruit. Staff decided that the candidate needed the leadership skills to work autonomously so that they would require less intensive support.
The PCN therefore sought a more senior pharmacist with an existing independent prescriber qualification and relevant experience to support and drive the PCN agenda, even though this would require additional ‘top-up funding’ by the practices. Staff outsourced the recruitment and support to Soar Beyond to ensure they would find the right candidate.
Soar Beyond supported the practice by:
- advertising to attract a clinical pharmacist with the right skillset, as well as screening and testing candidates for fit with the defined criteria
- designing and leading a rigorous needs-based interview with GP participation
- helping the PCN to sell the role to potential pharmacist candidates
- supporting the PCN to employ and agree suitable terms and conditions.
After a thorough screening and interview process, a suitably experienced candidate was interviewed in September 2019 with an offer made to start work in January 2020. The delay in start date was due to a lengthy notice period, which is typical for skilled professionals—something that should be considered when beginning recruitment.
The benefits for the PCN, practices, and pharmacist included:
- clarity of expectations and deliverables among practice staff
- a clear and structured 90-day induction plan with agreed KPIs aligned to the PCN’s needs and priorities, such as streamlining the repeat prescribing process across practices
- a structured development plan aligned to PCN’s goals and to the pharmacist’s existing competencies
- a supported pharmacist, without the practice being overburdened, who is well placed to upskill the remainder of the clinical and non-clinical team members
- access to the Soar Beyond SMART platform, which includes a suite of online resource, toolkits, and other implementation resources to enable the pharmacists to roll out new processes efficiently and effectively, without having to ’reinvent the wheel’.
The PCN has commissioned additional senior pharmacist support from Soar Beyond to provide regular coaching calls to ensure development and progress is kept on track through KPI reporting and deployment of milestones.
Although the whole process took 6 months, this was accelerated using external support and expertise, and prevented Didcot PCN encountering common pitfalls experienced by other PCNs, such as taking on inadequately experienced pharmacists or those that require significant support and supervision.
- ‘Working through the recruitment and induction process with the support of Soar Beyond has been strategically invaluable in terms of aligning my vision and values with those of the PCN Clinical Director and member practices. In my experience so far, this very alignment is crucial in effectively delivering the PCN Pharmacist role at scale.’ Ziad A Laklouk; PCN Pharmacist, Didcot PCN
PCN=primary care network; KPI=key performance indicator
Practice-based clinical pharmacists are growing in numbers and in importance in primary care. NHS England is now providing funding for PCNs to employ pharmacists and pharmacy technicians. Pharmacists will support PCNs with directed enhanced service delivery, the quality and outcomes framework, and other national and local incentive schemes. GPs and PCNs should therefore invest time in developing their pharmacist to get the best return on investment.
Managing Director, Soar Beyond Ltd
Director of Pharmacist Services, Soar Beyond Ltd
PCN pharmacists have an essential role in coordinating and supporting practices during the coronavirus pandemic to ensure continuity of care is as normal as possible in these unprecedented times. Key roles for the PCN pharmacist include:
- supporting and managing the repeat prescription process, conducting proactive searches to convert patients to electronic repeat dispensing to reduce the workload in the practice
- risk-stratifying patients to ensure that those with clinical need are seen by a healthcare professional
- ensuring that structured medication reviews are still conducted, albeit remotely
- providing point-of-contact advice to patients about medicines and addressing any concerns about interplay between specific medicines and COVID-19.
Soar Beyond’s SMART platform is acting as a hub, directing pharmacists to relevant, verified clinical and professional information. Soar Beyond has also set up a series of Rapid Response online workshops through their i2i Network to support pharmacists who are providing care remotely for patients with long-term conditions.
PCN=primary care network
- NHS England. Clinical pharmacists. www.england.nhs.uk/gp/our-practice-teams/cp-gp/ (accessed 6 April 2020).
- British Medical Association, NHS England. Update to the GP contract agreement 2020/21–2023/24. London: GPC, 2020. Available at: www.england.nhs.uk/publication/investment-and-evolution-update-to-the-gp-contract-agreement-20-21-23-24/ (accessed 6 April 2020).
- Mann C, Anderson C, Avery A et al. Clinical pharmacists in general practice: pilot scheme. Independent evaluation report: full report. Nottingham: University of Nottingham, 2018. Available at: www.nottingham.ac.uk/pharmacy/documents/generalpracticeyearfwdrev/clinical-pharmacists-in-general-practice-pilot-scheme-full-report.pdf
- British Medical Association, NHS England. Investment and evolution: a five-year framework for GP contract reform to implement The NHS Long Term Plan. London: BMA, 2019. Available at: www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf
- Andalo D. Number of clinical pharmacists expected to work in PCNs rises to 7,500 by 2023/2024. Pharm J 2019; doi: 10.1211/PJ.2019.20207066
- NHS England and NHS Improvement. Network contract direct enhanced service—Draft outline service specifications. NHS, 2019. Available at: www.engage.england.nhs.uk/survey/primary-care-networks-service-specifications/supporting_documents/Draft%20PCN%20Service%20Specifications%20December%202019.pdf
- NHS England. Network contract DES—engagement on draft outline service specifications: summary report. London: NHS England, 2020. Available at: www.england.nhs.uk/wp-content/uploads/2020/01/2020-01-30-pcn-services-engagement-report-1.pdf
- Wickware C. Pharmacists face same workforce crisis as general practice, warns CCA chief. Pharm J 2019; doi: 10.1211/PJ.2019.20207377
- Praities N. PCNs forced to recruit pharmacists with less experience owing to shortages, says NHS England director. Pharm J 2020; doi: 10.1211/PJ.2020.20207661
- Pharmacists’ Defence Association. PDA urgent guidance for all PDA members following a number of critical incidents involving GP practice-based pharmacists. www.the-pda.org/urgent-guidance-on-critical-incidents/ (accessed 6 April 2020).