Getting Started with Clinical Pharmacists in General Practice

ANALYSIS ■

Getting started with clinical pharmacists in general practice

NUALA HAMPSON

The NHS England scheme Tips for practices to develop the role of clinical pharmacists in • Understand the breadth, diversity and evolving nature of the role of the clinical pharmacist in general practice general practice is now • Identify what roles the pharmacist should undertake in your practice. Ensure well underway. With that everyone understands what role the pharmacist has phase 2 of the programme • Pharmacists are experts in medication; utilise this unique skill to the advantage now recruiting, and many of your practice • Recruit a pharmacist who can meet your identified needs and who will fit in with practices considering your practice team taking on a pharmacist • Support your pharmacist in training and development outside of the programme, Tips for pharmacists this article provides pragmatic advice for both • Know the practice – understand the skill mix, the population demographics and practices and pharmacists its strengths and weaknesses. Get to know all members of the practice team as individuals embarking on this new • Be clear about your capabilities and how they can benefit the practice. Be aware venture. of your developmental needs • Ensure that you can clearly articulate your role and its potential benefit to the he role of the clinical pharmacist practice. How does your role complement others in the practice? Tin general practice has been evolv- • Utilise your medication expertise to the best effect for your practice. Avoid ing on a small scale for many years.1-4 duplicating the work of others The launch of the NHS England Clinical • Be realistic about what you can achieve in your allocated time Pharmacists in General Practice programme has resulted in a rapid increase Table 1. Top tips for general practices and clinical pharmacists on working in general practice in the number of pharmacists working in general practice in recent years. The role can utilise a pharmacist in many ways. is also being developed in other coun- Hence, it is important for a practice to tries, particularly Canada and Australia. identify how a pharmacist can best uti- This article draws on the existing pub- lise their skills in their particular prac- lished evidence base and the personal tice. A small-scale study in the Midlands experience of a practice-based pharma- and East region of England identified cist to provide tips and advice for prac- that pharmacists employed by general tices considering taking on a pharmacist practices over a number of years prior to and for pharmacists thinking of moving the NHS England programme undertook to this new role. The top tips for prac- a range of roles.6 The position focused tices and pharmacists are summarised around three key areas, namely: medica- in Table 1. tion-related administration; quality, safety and education; and patient-centred clini- Role of the clinical pharmacist in cal roles. Table 2 lists some of the tasks general practice that might be undertaken within these The role of the clinical pharmacist in three areas. general practice is broad and diverse.2-5 GPs who routinely work with clinical Different pharmacists have different pharmacists in general practice value experience, skills and areas of inter- medication expertise as the unique skill est. Practices have different needs and that pharmacists bring to the general prescriber.co.uk Prescriber March 2018 ❚ 25 ■ ANALYSIS l Clinical pharmacists in general practice

6-9 practice team. This skill can be uti- Clinical Examples of responsibilities described by employing GPs lised in many ways to save GPs’ time, pharmacist role to support clinical decision making for individual patients, and to improve prac- Medication- • Medicines reconciliation of hospital discharge forms and 6,10 tice-level systems and processes. A related hospital clinic letters clinical pharmacist in general practice is administration • Responding to repeat prescription-related medication queries a unique role and is new to most prac- • Responding to medication-related ‘tasks’ on the clinical system tices. Pharmacists are not there to act as • Providing expert advice in relation to medication-related cheap GPs; their role should complement queries to GPs and other clinical members of the team that of GPs and other clinical staff. regarding individual patients or situations on an ad hoc, Evidence shows that the role of the on-demand basis, eg what drug to prescribe in a given pharmacist tends to evolve over time as situation, advising on the significance of specific drug a trusting professional relationship devel- interactions ops between GP and pharmacist.6,7 The development of this relationship requires good communication, time and effort on Strategic quality, • Designing and undertaking clinical audits in relation to both parts.7,8 GPs may need to make safety and safety, quality or cost of prescribing time to understand the pharmacist’s role, education • Setting up and reviewing protocols in relation to prescribing and pharmacists must be clear about • Educating reception and administrative staff on the repeat their capabilities, their developmental prescribing system and appropriate protocols needs and how their role can benefit the • Leading on projects such as review of a certain practice. Everyone in the practice needs therapeutic area or drug group to optimise safety to understand what role the pharmacist and quality of care, eg monitoring of high-risk drugs, has to ensure their successful integration prevention of coronary heart disease and utilisation.7 Pharmacists themselves • Undertaking quality pieces of work to achieve Quality can facilitate this by being visible within and Outcomes Framework points, enhanced service the practice, engaging with staff at all specifications and Care Quality Commission targets levels and being able to clearly articulate • Keeping up to date with clinical guidelines and the scope of their role and its potential implementing strategies to ensure that the practice is impact.6,7 Regular review of the pharma- treating patients in line with these cist’s role should be planned so that it can • Educating clinical staff within the team on changes to both be extended and developed in line with the local and national prescribing guidelines and formulary expanding competences of the pharmacist • Keeping up to date with medication safety alerts and and the changing needs of the practice. acting on them on behalf of the practice • Regularly attending practice meetings relating to Tailoring the role to the prescribing, clinical issues and significant events individual • Liaising with external staff on work streams, eg care home Pharmacists come to the role with differ- pharmacists, community pharmacists, CCG medicines ing levels of knowledge and experience.11 management team This will depend on the length and setting of their previous work experience; Patient-centred • Medication review in a range of patients, including attainment of additional qualifications in clinical roles patients with polypharmacy or multimorbidity; titration clinical pharmacy and prescribing; and on of medication such as analgesics or antidepressants; their individual areas of interest. Ideally, deprescribing; monitoring of patients on specific groups practices and pharmacists should meet of drugs, eg anticoagulants or disease modifying anti- prior to recruitment to discuss the needs rheumatic drugs (DMARDs) of the practice and the skills and inter- • Medication review in care homes ests of the pharmacist in order to ensure • Chronic disease management: routine review of stable that a good fit is found. For example, patients with chronic conditions such as hypertension, some pharmacists are keen to upskill ischaemic heart disease, diabetes, asthma, COPD, in the area of acute illness, while oth- hypothyroidism, chronic kidney disease, persistent pain ers prefer to focus on chronic disease. • Participating in telephone triage, assessment and Practices should consider the existing treatment of minor ailments within competence (NB. most skill mix of their practice team and the pharmacists require additional training for these roles) demands of their population when considering what roles they would like a phar- Table 2. Roles of clinical pharmacists in general practice6

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macist to undertake. Pharmacists should Practices and pharmacists should widespread.3,4 Even pharmacists with have a clear focus on how they would like consider the dynamics of the existing many years of clinical experience may to develop their skills in general practice. practice team. GPs who routinely work need to develop skills specific to general There are many possible areas of general with clinical pharmacists in general prac- practice such as the use of clinical sys- practice in which a pharmacist can have tice feel it is important to recruit the right tems, and consultation and examination an impact. However, a common mistake person, both in terms of skills that would techniques.12 All pharmacists will need is for a pharmacist to take on too much meet the needs of the practice and an a comprehensive induction into general and then realise the workload is too great individual who would fit in with their par- practice, which should include an intro- for one individual. Table 3 describes a ticular practice team.6 duction to the extended team, introduc- typical day for the author working as a Where possible, practices and phar- tion to local policies and procedures, pharmacist in general practice. macists considering this new role should mandatory training and clinical systems Logistical issues should also be speak to those with experience to get a training. taken into account. Many pharmacists realistic insight into the practicalities of NHS-funded clinical pharmacists in retain a role in their original area of prac- the role and to gain advice and support. general practice have a commitment to tice, and part-time roles in general prac- A list of participating sites in the NHS undertake training and development, tice are common. The practice needs to England programme can be found on the which is funded by Health Education consider issues such as room availability NHS England website.11 England and provided by the Centre for and the pharmacist needs to consider Pharmacy Postgraduate Education, dur- the pattern of the working day in general Training and development ing their first 18 months. Practices will practice, which may differ to other sec- Until recently, the role of the clinical need to allow time for the pharmacist to tors of pharmacy. pharmacist in general practice was not attend training events and to support the

Time Tasks Notes

8:00– Check task list and discharge form list Tasks usually from reception staff and GPs, for example: 8:45am • GP queries – formulary issues, requests for advice, medication queries, referring patients for specific intervention or advice • Reception staff queries – alignment of medication, queries from patients, problems with prescriptions

8:45– Clinic • Face-to-face 20-minute appointments for medication review, chronic 11:25am disease review (eg asthma, COPD, hypertension, coronary heart disease), referrals from GP, eg newly started on anticoagulant requiring counselling, or patients requesting appointment to ask advice • Telephone follow-up appointments at end of clinic

11:25am– • Clinic follow up • Follow up any queries or tasks that have arisen from morning clinic 2pm • Medicines reconciliation of discharge • Complete task list and discharge forms forms and relevant clinic letters • Debrief with GP where necessary regarding patients seen that (rheumatology) morning or discharge forms • Completion of tasks from SystemOne • GP available during this time for general (informal) catch up task list and discussion about any current issues or problems, work • Lunch planning, etc.

2–4pm Admin time • High-risk drugs monitoring (eg DMARDs, oral anticoagulants, lithium) • Clinical audit • Action safety alerts • Review protocols (repeat prescribing, high-risk drug monitoring, process for reporting errors and significant events,etc .) • PINCER reviews • CCG prescribing action points • Support reception staff with training in relation to repeat prescriptions, CCG medicines management switches, etc. • Support admin staff running chronic disease recalls in relation to the Quality and Outcomes Framework, enhanced services, etc.

Table 3. A day in the life of a clinical pharmacist in general practice prescriber.co.uk Prescriber March 2018 ❚ 27 ■ ANALYSIS l Clinical pharmacists in general practice

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