These commentaries by John Macgill represent his opinions only and not those of any Ettrickburn client.

Three Nations Three Practices

Community Pharmacy Eliminating Hepatitis C

Homeless People make Glasgow

Heart Failure – we can get treatment right for everyone

Bundles of Safety

Community Pharmacy’s Leader in Scotland

CPO: On the Road to Achieving Excellence

Pharmacy technicians may become prescribers

Profile: Dr Norman Lannigan OBE

Profile: Jonathan Burton MBE

Profile: Clare Morrison MBE

Deep Dive Pharmacy

Mind the Gap - Diagnostic Skills for Pharamacists

Bundles of Safety

Supporting Excellence - Alison Strath Interview

2018 Pharmacy Forum Agenda Launched

Which Referendum to Choose

Three Perspectives on Pharmacy and Mental Health

Pharmacy and the New GP Contract

Bordering on Problematic

Recognised by the Queen and her community

VACANCY Reporter/Researcher: Health and Care Policy in Scotland

Prescribing in Mental Illness – A Practice Pharmacist’s Perspective

What Matters to You? Communication in Pharmacy

Prescribing in Mental Illness – A Patient’s Perspective

Focusing the Vision: Dr Rose Marie Parr on the new strategy for Scottish pharmacy

All the things that could go wrong - looking ahead to the SNP conference

Ask Once, Get Help Fast? Pharmacy and Mental Health

Automation and Delegation in Pharmacy: Understanding the Moving Parts

Initiatives Highlight Potential of Community Pharmacy

Pharmacy First in Forth Valley One Year On

Trying to concentrate on the day job

Health and the Local Elections – a strange silence

The Pharmacist Will See You Now – The Growth of GP Pharmacy

Montgomery’s Review – Dr Brian Montgomery answers questions on access to new medicines in Scotland

An afternoon with SMC

Pharmacists at SMC

SMC – are drug firms voting with their feet?

Radical Surgery on the Horizon for Scotland’s NHS

The Future’s Bright – in General Practice

Community Pharmacy in a Changing Environment

Disclosing payments to doctors – has Sir Malcolm done the pharma industry a favour?

Health and Care in the First Minister’s Programme for Government

CMO: Scotland’s pharmacists “absolutely ideally placed” to practice Realistic Medicine

Profile: Maree Todd – MSP and Pharmacist

Scottish Parliament Health Committee Work Programme

Scotland’s new NHS – a Summer of Speculation

Scotland’s New Health Committee

Two million voices in Scotland – is integration the big opportunity to listen?

Medicines – levelling the playing field

Key appointment raises the bar for health & social care partnerships

What did our new MSPs do before?

SMC says no then NICE says yes – three times

SNP promises single formulary and a review of Scotland’s NHS

More Generous than the CDF – but less transparent

Comparison of Funds: New Medicines v Cancer Drugs

Bonfire of the Boards? SNP signals NHS Review

A tribute to five retiring MSPs

New Medicines Review - Health Committee sends findings to Government

Medicines New & Old in the Scottish Cancer Strategy

Great Ambitions, Slow Progress – New Models of Care in Scotland

Scottish Minsters Demand Up-Front Medicine Price Negotiation

Opportunity and Disappointment: MSPs Investigate New Medicines Access

Scottish NHS Strategy calls for 'Realistic Medicine'

The Scottish Model of Value for Medicines: Taking Everything into Consideration

When SMC Says No: An Access to Medicines Lottery

Reviewing the Review: Access to New Medicines in Scotland

A day of psephology and kidology

Insulting the Lifesavers

Worthy of Mention – Health and Science in the Honours List

News Silence from North of the Border

A Christmas PPRS Present from Pharma

Wednesday, March 20, 2019: Three Nations Three Practices

Ahead of the first Celtic Conference of Pharmacy in Edinburgh on 26 March, this article was published in Scottish Pharmacist Magazine (page 6)

At the end of March, the first Celtic Conference will bring together pharmacists from Scotland, Wales and Northern Ireland in Edinburgh. The subjects under discussion demonstrate the different approaches being taken to common problems across borders. Ahead of the conference, John Macgill focuses on the drive to increase access to GP practice-based pharmacy across the three nations and examining whether that ambition is being achieved at the expense of other pharmacy services.

Gordon Rushworth is a lecturer, researcher and clinician working in the Scottish Highlands. Half of very week, he is advanced pharmacist practitioner working with patients at a GP practice. On other days he supports pharmacists to improve their consultation, clinical and prescribing skills; teaches undergraduate medical and pharmacy students; and undertake practice research.

“I've held a portfolio post for the majority of my career,” he says, “and would highly recommend it to anyone. It's refreshing to be able to hold key roles in multiple organisations or sectors of practice.”

As part of the local practice team, Gordon runs a polypharmacy clinic for every patient on a dozen medicines or more, making his own prescribing decisions. He is contributing to a redesign of medication review systems that has seen almost four in ten patients on a repeat medicine move onto a serial prescription.

“I work within a team which also includes advanced nurse practitioners. We now see all the on-the-day presentations instead of GPs and undertake the majority of house visits for acutely unwell patients. The patients I assess, from across the age and acuity spectrum, are undiagnosed and are not triaged. There is GP support available should we need it. I'm counted within the clinician numbers for any given day to ensure the practice has adequate cover – my role is integral, rather than ancillary, to the operation of the practice.”

By April of 2018, driven by £16 million of Scottish Government funding to recruit pharmacists into general practice teams, 201 whole time equivalent pharmacists and 47 pharmacy technician posts had been filled. The advent of a new Scottish GP contract that removed responsibility for ‘pharmacotherapy services’ from doctors, has helped drive recognition of the expert role of pharmacy – and encourage buy-in from doctors.

When she spoke to Scottish Pharmacist late last year, the question for Scotland’s Chief Pharmaceutical Officer, Professor Rose Marie Parr, was how best to grow the current 50% of practices with input from a pharmacist or technician to 100% over the coming three years. Often, newly appointed practice pharmacists have come into the role by splitting their time with their existing community pharmacy work. She is an enthusiast for a mixed economy, portfolio approach, telling Scottish Pharmacist:

“It is also important that people are positive about their jobs and their futures, that they don’t feel stuck in silos but can benefit from an integrated service to allow them to move between settings and, equally, to stay where they are and do new things.”

Matt Barclay, Director of Operations at Community Pharmacy Scotland recognises both benefits and challenges from meeting the broadening expectations of the pharmacy workforce:

“Community Pharmacy is experiencing a challenging period as we are seeing the recognition of the importance of community pharmacy in primary care, while at the same time having some staff choose to work in general practice pharmacy instead. Our focus is on keeping community pharmacy an attractive career choice and developing the services that we can provide.”

Matt adds: “The clear benefit of general practice pharmacy is taking pressure off GP time, and to improve this further, we would like to see community pharmacy getting access to patient records so that we can further support prescribing and medicine review for patients.”

Russell Goodway, Chief Executive of Community Pharmacy Wales says his organisation welcomes the notion of greater collaboration between community pharmacists and general practitioners, either through local community-based arrangements or working together through the GP cluster model.

“A one size fits all approach such as just employing community pharmacists in GP practices isn’t always the best solution and isn’t what’s being asked for by the Welsh Government in terms of developing community pharmacy services in Wales. Indeed, when faced with increased recruitment pressures on community pharmacies in some parts of Wales, taking some of the potential workforce out of potential employment might actually worsen the situation in terms of accessing community pharmacy. It is often better to look at alternative models, such secondment for one day a week, rather than direct employment.”

In late 2015, the Welsh government started a process towards recruiting primary care pharmacists to work across its 64 clusters, each cluster serving between 30 and 60,000 people depending on geography. At the same time, an increasing number of GP practices are directly employing a pharmacist as part of their team.

Lloyd Hambridge is a cluster pharmacist in Aneurin Bevan Health Board, working with another pharmacist across seven GP practices. He also now works two days a week embedded in a single practice. Portfolio working across different settings is, he says, common. In his Board, two colleagues split their time between cluster and community pharmacy jobs. He moved from working in a hospital.

“It was probably two thirds secondary care and a third community pharmacists moving into these roles, so we had to make sure that we weren't losing too many pharmacists from hospital settings as opposed to community, but I think the Wales model means a lot of them have a multisector role and a portfolio career. Our Chief Pharmaceutical Officer is very forward thinking and innovative and he understands the value of community pharmacy, so a lot of community pharmacists want to stay there because they are seeing it become more interesting and varied, and quite clinical as well, with the roll out of our Common Ailment Service and the ‘choose pharmacy’ campaign.

Northern Ireland is currently suffering a crippling pharmacy workforce crisis, according to Adrienne Clugston, Operations Manager for the Ulster Chemists’ Association (UCA).

“We’ve gone from a chronic oversupply of pharmacists to a situation where pharmacies are having to reduce opening hours through lack of pharmacist cover,” she says. “The factors causing this are varied: many newly-qualified pharmacists left for Ireland or GB or further afield when they couldn’t get regular work, the number of graduates coming through has reduced, plus the recruitment of practice-based pharmacists has turned the situation 180 degrees in just a couple of years.”

Northern Ireland’s Department of Health is spending £15m to deliver Practice Based Pharmacy support to all GP practices across Northern Ireland. Recruitment to these permanent posts is in six waves and, with the first four waves completed, 227 pharmacists – filling 189 WTE posts – have been appointed to GP practices across Northern Ireland.

Adrienne Clugston from the UCA says there has been a price to pay.

“New roles for pharmacists especially within primary care is a very welcome development and is recognition of the value they can bring to the NHS, but the fact is there are just not enough pharmacists in Northern Ireland to go around. All sectors in pharmacy are suffering.

“UCA raised this issue more than a year ago with the Department of Health who seemed to be oblivious, if not unsympathetic, to the unfolding situation. UCA was informed that an NHS-wide workforce review was getting underway and that pharmacy would be taken into consideration. Unfortunately, we have not seen the outcomes of that review yet and the recruitment of practice pharmacists has continued unabated.”

As well as his day to day work as a community pharmacist, Jonathan Lloyd is Director of Integration for PACT – Primary Care and Community Together – a Northern Ireland community interest company set up to look at how community pharmacy can integrate with other health and care providers in their communities. He says the recruitment of pharmacists into GP practices has been a mixed blessing:

“Speaking personally as a community pharmacist, I suppose the positive would be that I now have somebody within the practice who understands what community pharmacy is talking about. We have advocates within the practices who, as they’ve generally been drawn from community pharmacy, know why are asking things that may seem pedantic to a GP.

“The problem is that they have been drawn from community pharmacy. So we are starting to see a crippling workforce crisis appearing. If you put an advert anywhere for a pharmacist, you are unlikely to get one. Locums too are becoming extremely difficult to find. We have gone from perhaps an oversupply of pharmacists to a situation where we are struggling.

“I don't think the Department did a workforce plan before they fired the gun on this and they are continuing to aggressively recruit into practices without taking any account of what is happening within community pharmacy.”

A spokesman for the Department of Health told us an ongoing review is underway of the pharmacy workforce, incorporating pharmacists, pharmacy technicians and pharmacy support staff, to inform HSC workforce development needs for the next ten years. It is the intention to complete that review by autumn 2019.”

UCA and CPNI [Community Pharmacy Northern Ireland] have both proposed a pause on the recruitment of practice-based pharmacists to allow the workforce to replenish.

But the spokeswoman for Northern Ireland’s Health and Social Care Board says the fifth wave of pharmacists will take up post in the first quarter of the next financial year, with the final group taking up post during 2020, filling approximately 294 WTE posts.

She adds: “Practice Based Pharmacists come from a broad range of backgrounds and sectors, including community and hospital pharmacy, academia and prescribing support roles. The posts have attracted both local pharmacists and those who have been working in Great Britain and the Republic of Ireland.”

She added: “The pharmacist workforce has responded very positively to calls for the new roles in general practice causing a short term pressure on other employers. This has been recognised and the Health and Social Care Board and Department of Health are working with stakeholders to help mitigate any negative impact particularly on community pharmacy staffing levels, over the final two waves of recruitment during 2019 and 2020.”

Scottish practice-based pharmacist, lecturer and researcher, Gordon Rushworth, wonders if there is a solution that’s about community pharmacy not about practice-based or secondary roles:

“Make the community pharmacist job more appealing. It sounds somewhat crass, but I think it's true. People don't tend to leave appealing jobs. Whether it's pay and conditions, the lure of an NHS pension, the lack of weekend and evening working or a perceived workload reduction from a busy pharmacy dispensary – I've heard all these used, in part, to describe why community pharmacists have moved to another sector of practice.

“However, the biggest driver that I've heard from community pharmacists cum GP pharmacists is the perception that the GP jobs will be far more clinical and patient-facing and, in many instances, community pharmacists are willing to take pay cuts to do this.

“I think community pharmacy needs to listen to those leaving its ranks and think what changes it's able to make to retain staff.”

For more details of the first Celtic Pharmacy Conference in Edinburgh on 26 March 2019 go to www.pharman.co.uk/celtic-conference. Attendance is free for healthcare professionals.