Since there is such a huge GP workforce crisis facing GP surgeries at the moment in the UK, it makes sense that pharmacists, who are vastly underutilised, help support these practices and fit into the multi-disciplinary team that already exist successfully with other healthcare professionals. I am fortunate enough to be considered as one of the first 490 pharmacists working in GP practices in the NHSE phase one pilot scheme (now known as Wave One) as part of the Five Year GP Forward View and feel that I have already made a significant difference in how pharmacists can successfully work in a multi-disciplinary team effectively and as part of the general practice team to deliver excellent patient care and significantly reduce GPs workload.
My usual day-to-day role may differ from other practice-based pharmacists as it depends on the needs of the practice one works in. Unlike in community pharmacy where a locum pharmacist can almost seamlessly know the activities that needs to be done during their working shift, it is wholly different in general practices as there are a variety of roles that a pharmacist undertakes and the ‘one size fits all’ approach does not apply so one cannot easily ‘locum’ from one practice to another unless they have gained a wide variety of skills and qualification which can take years to hone.
I currently undertake the following activities which may expand as I continue to develop my role further and in no particular order:-
- Face to face and telephone appointments for medication queries and advice.
- Annual medication reviews for patients with long-term conditions & newly-registered patients.
- Annual diabetes review clinics
- Medication management and implementation of repeat prescription services including EPS.
- Monitoring high-risk medications such as DMARDs, Warfarin, Lithium
- Administer influenza vaccines to at-risk groups for NHS patients
- Monitoring prescribing costs, advising on potential savings and working with CCG colleagues
- Electronic Frailty Index work on the severely frail patients
- Implementing Clinical, CQC & QOF audits and reviewing data
- Developing relationships with local community pharmacies help with queries relating to patients medications and advising suitable patients for MURs and NMS.
- Practice support and training
- Reauthorisation and printing Acute and Repeat prescription requests following Medication review which is then ready to be signed by GP unless other issues are found which is then referred on.
- Consulting with hospital regarding on-going care when required.
- Carrying out Medicines Optimisation scheme as decided by CCG using tools such as PrescQipp.
- Carrying out unplanned admission care plan reviews and setting up new patient care plans
- Reviewing Discharge notifications from hospital, amending medications on patient’s notes and medicines reconciliation.
- Reviewing clinic letters and adding/change/discontinue based on the recommendations
- Seeing patients and offering advice on their medications if required.
- Reviewing pathology results for multiple conditions and dealing with accordingly and discussing results with patients.
- Level 2 & 3 Medication Reviews
- Polypharmacy Reviews
- Ordering and interpreting blood tests
- Referral to other HCPs as appropriate
- Dealing with medication requests sent by fax or email from secondary care/consultants
- Dealing with drug safety alerts from MHRA and industry
- Opportunistic telephone consultations to discuss issues such as compliance and optimising patient care
The above-mentioned activities are what I do and is spread out in a four day week for a general practice that serves 10,000 patients which means I get to make an enormous difference to that particular surgery. This benefits the patients and significantly reduces GP and admin hours to ensure better continuity of care. However, I do work at another general practice surgery for one day a week (albeit with a 4000 patient size list) and only manage a smaller portion of the above-mentioned activities and am unable to conduct face-to-face consultations which I enjoy the most due to lack of time and although I have made a difference in terms of medicines management and audits, I do not feel I am an indispensable member of the team compared to the practice where I work four days a week. This is important, especially with the NHSE Wave 2 pilot sites where the funding only allows one pharmacist to be dealing with an average of 30,000 patients in a week which means they have to be working in three to four different general practices per week. I feel this is such an insignificant time for the pharmacist to make their mark and almost setting up to fail, as practices may not fully value the contributions of the practice pharmacist. This has led to others commenting that this is more of a political statement for the government to ensure that there is a pharmacist in every GP practice in five years time.
There are wide-ranging and different expectations as to what GP practices think practice pharmacists are able to undertake and some practices who have not used pharmacists before unfortunately have high expectations that practice pharmacists, especially independent prescribers, can deal with the more the serious and complex cases as well as running minor illness clinics from day one after their induction.
The PDA has already highlighted a case from last year where a newly-appointed prescribing practice pharmacist, with no formalised qualification to conduct minor illness clinics, prescribed antibiotics for a patient who had chest infections but sadly died three days later due to heart failure as other red flag symptoms were missed and not fully documented. I believe all practice pharmacists should be trained on the basic clinical assessment skills for each different body systems to recognise any red flag symptoms to refer to the duty GP or A&E during their face-to-face clinics rather than dealing with the urgent case themselves as some are already doing using their IP qualification without the pre-requisite training and experience as not all the IP courses offer this important skill. Not only do pharmacists deal with acute and urgent care patients that are high risk, they do so with a fraction of the cost of a locum GP (who are commanding on average of around £100/hr) at Band 7 or Band 8a rate even though the risks are the same as the GP. What I fear is that job security may have played a part and that pharmacists are quickly being seen as ‘cheap GPs’ that will damage the profession long-term rather than being seen as another imperative member of clinician working in a multi-disciplinary team.
Responsibility & accountability to signing prescriptions
Another expectation general practices have is for all pharmacist prescribers to be batch signing acute and repeat prescriptions to take the burden away from the GP. During the IP course, it was mentioned numerous times that when signing a prescription, you are fully accountable and responsible for that patient so to absolutely satisfy yourself that you are signing for the best interests of the patient and that all monitoring, counselling and indication has been fully checked and documented as essentially you are re-confirming their condition when you sign their prescription. This is extremely difficult to do if you do not have any direct involvement with the patient yourself, whether that is face-to-face or telephone contact, and that batch signing prescriptions goes against this principle. I have known numerous pharmacists being pressurised to undertake this activity for job security and also at such low pay for the high risks involved.
What I hope to do in the future following extensive supervised training, formalised accreditation such as the Advanced Clinical Practioners (ACP) course and other relevant certified qualifications, are telephone triages for minor ailments, determining if I can suggest treatment or if it needs to be referred to GP as well as conducting an urgent & acute illness triage in surgery to reduce the burden of the GP who can concentrate and deal with the more complex patients.
I very much enjoy the wide variety of roles and activities I undertake as a practice-based pharmacist and enjoy both the administrative side of medicines management which does not require any IP qualification input as well as the face-to-face contact with patients in my chronic disease clinics and that I am able to utilise my prescribing qualifications to manage their long-term health and condition. I also enjoy my interaction with the local community pharmacies and help forged great working relationships along with the GP team to benefit the patient and help streamline any new medicine changes from hospital discharges to referring patients to community pharmacies for MURs and NMS.
I do however want to give realistic advice to pharmacists wanting to move into this sector as an alternative pharmacy career, especially from community pharmacy, not to expect lucrative salaries as many wrongly believe that by becoming an independent prescriber working in general practices, their earning potential will significantly increase compared to community pharmacy, mainly due to on-going pharmacy cuts from the government in the sector and the fall of locum rates in recent years. There are unfortunately some pharmacists that under value themselves and are accepting prescribing roles at community pharmacy salaries or less with similar responsibilities as GPs in some respects. There are however some who are not in advanced practice roles or even prescribers that can command upto £60K a year. It all depends if you can negotiate and implement your clinical skills effectively as well as providing value for money to the surgeries by doing work related to QOF.
Another important factor to weigh is the high indemnity insurance costs and level of cover as they vary amongst different providers with many exclusions depending upon experience and expectation. Not all GP practices pay for the pharmacist’s indemnity insurance and will cost around £1500 per year at £10 million cover at the moment which may rise annually that is the minimum cover GPs are required to have as the risk is the same for both professions in a general practice setting, especially if conducting face-to-face clinics. GPs pay at least five figures for their indemnity insurance yearly so for pharmacists to pay around £1.5K is minimal given the context.
Studying after working hours
When working in the general practice sector, the job does not finish at the typical 9am-5pm slot as you have to be clinically up to date more so for any new drug changes and new emerging drug trials coming through as well as regular changes to local and national guidelines and require to study these in your own time at home, whether that is after work or during your days off. Attending conferences such as the Pharmacy Show and the Clinical Pharmacy Congress will give good insight and build up your CPD portfolio and the pending revalidation as well as attending separate GP & nurses training courses privately. I thoroughly recommend pharmacists interested in keeping their clinical knowledge up to date to sign up for the NICE daily medicines awareness service and the links are posted below in the resources section below should you wish to prepare yourself as to what type of resources you need to be reading around when preparing to work in this sector.
Advice for prospective GP practice pharmacists
For those who haven’t been put off yet and are still reading this with keen interest, then I would advise you to speak and possibly work shadow other practice pharmacists to discuss about their role and how it differs from practice to practice as well as learning the different GP computer systems. Also there are other providers that can be found online that offer good training and expertise about practice pharmacy roles and activities, some charge at quite considerably high cost, but you would still need to take the initiative to contact practice managers to give a lift pitch yourself and be proactive to make the role your own.
By Siddiqur Rahman
Oxford Handbook of General Practice – 4th edition (2014)
Chantal Simon et al ISBN: 9780199236107
Avoiding Errors in General Practice (2013)
Kevin Barraclough et al. ISBN: 9780470673577
General Practice at a Glance Paperback (2012)
Paul Booton et al. ISBN: 9780470655511
A Guide to Laboratory Investigations (2013)
Michael McGhee ISBN: 9781908911537
Clinical Pharmacy Pocket Companion (2015)
Alistair Howard Gray et al ISBN: 9780857111579
NICE Clinical Knowledge Summaries (CKS)
General Medical Services (GMS) contract – Quality and Outcomes Framework (QOF)
NICE daily medicines awareness service sign-up