Skill mix: Can pharmacists and community pharmacy rescue general practice?

Pharmacists could play a vital role in primary care and help support GPs to meet patient demand, but a number of issues need to be resolved, says Dr Mark Spencer.

Much has been written about the severe workload and workforce issues brought about by ever increasing demand and dwindling numbers of GPs. The introduction of clinical pharmacists into GP practices is seen as one solution to this real and very significant problem.

What will this look like as pharmacists bed into their new roles and what will the future then look like for community pharmacy?

I have led on the recruitment of clinical pharmacists into five practices in my locality, and discussed how it has gone for others across Lancashire, and it’s quite clear to me that there is real enthusiasm amongst pharmacists to use and develop their clinical skills more widely.

Enthusiasm for clinical pharmacist role

The volume of applications for these new posts was high. The overall positive attitude, willingness and ambition of those applying was very evident but the vast majority of candidates lacked direct clinical experience. Most had a background of working within community pharmacy, but without the education and training that would enable them to safely manage patients in a GP practice.

There is certainly an excellent education and training package being provided as part of the initial pilot project, including prescribing accreditation, but bringing those pharmacists up to the clinical level of being autonomous within the supportive environment of a GP practice will take up to two years in most cases. 

Clinical pharmacists in general practices are therefore not a quick fix. The potential though is significant, covering areas such as same-day access for patients with minor ailments, managing complex patients with polypharmacy, managing the whole myriad of prescription queries and acting as the clinical link with local community pharmacy, to name but a few.

Each of these tasks would have a real impact on reducing GP workload.

The role of high street pharmacists

I also wholeheartedly support local high street pharmacies. In areas of high deprivation, such as where I work, they are an integral part of the community.

In general, people are much more relaxed about walking into a high street setting than a health centre. The local pharmacy is also one of the only places where someone can simply walk straight in and ask to speak to a healthcare professional.

I also believe that it’s entirely possible for the high street or supermarket pharmacy to be fully integrated with primary care and GP practices without having to relocate everyone into the same building.

In Fleetwood, we have recently opened up the full GP clinical record to our community pharmacists. This has been with the support of all local practices, the CCG and the local pharmacy committee and is compliant with all NHS information governance requirements. Accredited pharmacists now have full ‘read and write’ access to the GP records. This is the first essential step to full integration.

Where does that leave community pharmacy? There is a danger that with the migration of pharmacists into GP practices and the co-location of pharmacies themselves into ‘health villages’ the high street pharmacy could become an endangered species.

Making best use of pharmacists

So what issues need to be resolved to ensure that primary care makes the best use of pharmacists

Education and training
Structured clinical education is difficult for high street pharmacists to access but is an essential component of them being able to safely take on more complex clinical care, as is prescribing accreditation. This again is difficult due to the lack of availability of GP mentors.

Pathways of care and local protocols
These are very common in GP practices with regards to nurse-led long-term conditions clinics and standardised care across practices in a neighbourhood, but have never been produced with ‘off site’ pharmacists in mind, as far as I know.

Contracting issues
The current contracting process is fragmented and does not lend itself to patient-centered, community-based, multi-provider whole pathways of care. Let’s start contracting for patient outcomes and leave providers to organise how to meet those outcomes and distribute finances.

Clinical responsibility and indemnity
This is the hottest topic in town. The current perception of GPs is that all litigation cases seem to land at their door, irrespective of the complexity of the case or the multitude of other services that were involved in a particular patient’s care.

Clearly-defined clinical roles and responsibilities across a whole patient journey covering long term care and not just single episodes is required, as well as organisational insurance and individual indemnity coverage.

Once all of these aspects are in place then I can certainly see pharmacists directly managing patients with more complex urgent care needs, as well as playing a full role in long-term conditions management, irrespective of the setting in which that pharmacist is working. 

For example it would be perfectly feasible for an accredited pharmacist, even in a high street pharmacy, to be initiating and discontinuing medication within agreed protocols of care and then taking responsibility for monitoring and review. This is very much the accepted model for community matrons so why is it so alien to think of high street pharmacists also taking on this role? This would then be true integrated care.

  • Dr Mark Spencer is a GP in Fleetwood, Lancashire, medical director of FCMS and co-chair, New NHS Alliance

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