The following article is published in this month’s edition of Scottish Pharmacist magazine: http://bit.ly/2oW1Ark

The Scottish Government has promised that, by 2022, every GP practice will have access to a pharmacist with advanced clinical skills. John Macgill reports on progress towards this goal, and what it means for pharmacists and patients. 

“There really is no typical clinical day in general practice,” says Elaine Thomson, Locality Pharmacy Team Leader for the Dundee Health and Social Care Partnership. “There will be referrals from GPs and practice nurses with medication questions, arranging medication reviews, looking after complex discharges from hospital. Some people will run clinics, perhaps one session a week, and a series of patients will come to see them.” 

Elaine Thomson is not new to the world of local practice centred pharmacy. Tayside had the first practice pharmacist 20 years ago. Elaine, who also sits on the RPS Scottish Pharmacy Board, was appointed to a practice-based role 17 years ago. Even now, as a team leader, her clinical work still takes up much of her time. 

“There will be patients that I have on my own caseload that I need to follow up; patients that I need to go and see. I do care home reviews. I also cover the intermediate care unit one day a week as part of a multidisciplinary team, and will often talk to a person about their medication to see if there any things that we need to do to get it right before they go home. 

“The aim is to spend about 70 to 80 per cent of clinical time directly with patients and that varies a lot, I will spend time phoning people, or seeing them face to face in the practice or at home, depending on what’s most appropriate.” 

In a recent letter[i] to the Scottish Parliament’s Health and Sport Committee, Health Secretary Shona Robison reported that 101 WTE pharmacists and 12 WTE pharmacy technicians have been appointed to primary care posts as part of a three year £16 million programme, and that the NHS is on track to deliver the current target of 140 by March 2018. 

NHS boards are expected to target resources towards priority areas at a local level based on patient need, including areas with a greater proportion of elderly patients, areas of multiple deprivation, and where there are patients with multiple morbidities who receive a significant number of prescriptions and who have been identified as being statistically more at risk of hospital admission or readmission. 

Scotland’s Chief Pharmaceutical Officer, Rose Marie Parr, says the recruits to the new General Practice Clinical Pharmacist posts are from a variety of backgrounds: 

“We thought there would be a lot of hospital pharmacists but 50 percent are from community pharmacy and some were already working in primary care, so a real mix and perhaps more from community pharmacy than we would have thought. 

“In essence what we have found is that GP practice support needs a number of different things, so we have worked to get a skills mix into GP practices that’s right depending on need. We haven’t set a target for pharmacy technician recruitment but we know that they are an important part of that skills mix.” 

So how does the recruitment of pharmacists into roles supporting GP practice teams affect community pharmacists, many of whom themselves have clinical roles far beyond the High Street? 

“I know there is anxiety amongst community pharmacists as to where this leaves them,” says Aileen Bryson. Interim Director for the Royal Pharmaceutical Society in Scotland. “Actually, it is really important that the practice pharmacist works directly with the community pharmacist because there is huge amount that the community pharmacist can be doing, and knowledge they can share, and if they work well together locally they can capitalise on that. 

“There are some places where the role is a hybrid job where a pharmacist is working three days in the community and two days in the GP practice. Anecdotally, we are hearing this works really well and some people might suggest that that would be the best model. 

“I am hoping we get some sort of evaluation of all the different approaches and pilots and models as part of Prescription for Excellence. It is very much not one size fits all but it would be good to know from the evidence what works.” 

This view is mirrored by Community Pharmacy Scotland. Director of Operations, Matt Barclay, says the community pharmacy workforce is prepared to play its part in supporting the aims of the National Clinical Strategy and developing the framework to allow that to happen: 

“We acknowledge that pharmacists can and should be part of the solution within the new Community Health Service Vision currently being developed by Scottish Government under their new models of care. We would hope that pharmacists in these roles can facilitate continued strengthening of therapeutic partnerships within the wider primary care team. 

“We would also welcome innovative solutions bringing the community pharmacy network into helping provide improved patient care. In some areas this has involved community pharmacists sharing in the delivery of these new roles alongside their existing roles. We await with interest the evidence that comes from this type of model. Our initial understanding is that, for many pharmacy contractors, this has benefitted their employees and their business as expertise is shared and relationships strengthened with other healthcare professionals.” 

So what advanced skills are expected of General Practice Clinical Pharmacists? Rose Marie Parr says, while the new posts are usually being filled by experienced pharmacists, there is a broad spectrum: 

“It is a bit of an evolution so that when people are up to speed they need to be working to the top of their license. They’ll be patient facing and have their independent prescribing qualification in addition to some advanced or post graduate clinical training and skills, and consultation skills. We want people to be competent and confident clinically. They may not have all this from day one, but we would expect them to all be on that learning curve.” 

With this in mind, Anne Watson, Postgraduate Pharmacy Dean at NHS Education for Scotland, sets out how NES is supporting the education and training of these pharmacists. 

“There are three elements. The first is e-learning packages on the fundamentals of general practice, and therapeutics modules for common clinical conditions. The second is attendance at training camps supported by the general practice multi-professional team which includes training on telephone consultations, communication and clinical skills, and clinical decision making. The third is an advanced practice competency and capability framework, aligned to the RPS Faculty, which each is expected to complete. 

“NES is fast tracking these pharmacists through independent prescribing and clinical skills courses, and working with the individuals and their line managers in health boards.

In parallel, NES is piloting a ‘Foundation Framework’ for early years pharmacists with core and specialist modules, one of the specialist modules relating to work in general practice. 

Late last year, the RPS published a joint statement[ii] with the Royal College of General Practitioners of guiding principles for the role of general practice based pharmacists. 

“We were very clear that the skills are very different at the same time as being very synergistic,” says the RPS’ Aileen Bryson. “We need to have the pharmacists working in their own professional competency with their own professional autonomy in the same way as each GP works and the same way as the practice nurse works. Nobody is assisting the GP as such. They are all taking on roles where their skill mix is best used and knitting that together. 

“It is really important that they have one point of contact in their practice, somebody they can go to. But they also need an overall supervisor or mentor who is a pharmacist and that is the linchpin because they cannot be set adrift. There has to be a link with the wider primary care team, with the prescribing governance of their health board, and they have to have the peer support of other pharmacists.” 

Aileen Bryson says it is inevitable that pharmacists coming into new roles may take time to develop the role to its full potential. She says it goes deeper than just a division of tasks:

“Pharmacists are very risk averse, GPs are not. GPs are trained to touch patients and talk to patients right from the start. Our training doesn't do that yet but we are now asking pharmacists to test blood pressure or take blood samples. We have always said that some of our undergraduate training should be together and postgraduate training should be much more integrated, because that will get us the increased understanding between the two professions.” 

“I suppose change is scary,” says Rose Marie Parr, “but if you fear change in the NHS you are doomed because it changes all the time. For me there is nothing to fear for pharmacy: community or primary or whatever. But there will be change and it won’t be the same in the next five years as it was in the last five years.” 

So, what does this changed future look like from the perspective of an experienced practiced based pharmacist? Elaine Thomson believes it will see primary care realising the full potential of pharmacy: 

“I think our clinical skills will be being used much more. We will be seeing a lot more patients and we will be getting a lot more referrals from GPs, moving away from the prescribing support role even further. We will be much more patient facing, we will be taking on a wider caseload, managing more complex patients and developing more clinical skills to allow us to do that. 

“To do that the whole team is going to have to change. We're going to have to bring in more junior pharmacists and pharmacy technicians and have a whole team approach to be able to do much more of this stuff. The pressures on general practice are huge at the moment so there is massive potential for us to use the clinical skills that we all learnt at university, and to use them to improve outcomes for patients.”

[i] Health Secretary Letter: http://bit.ly/2ohUDhl

[ii] RPS RCGP document http://bit.ly/2eH0wmc