GPs and pharmacists have never traditionally worked closely together, but this is set to change as practice-based commissioners seek innovative solutions for redesigning services.
Pharmacists, with their network of easily accessible local facilities, are ideally placed to develop new roles and provide new avenues of access to services in the community.
Many are waking up to the fact that the future development of their small business could involve more than simply dispensing medicines.
They could, for example, play a key role in addressing health inequalities, providing public health and lifestyle advice, smoking cessation services, diagnostic tests or medication reviews.
This was the theme of a recent conference organised by the Improvement Foundation, which brought together GPs, pharmacists and primary care trusts (PCTs) to explore the possibilities of what community pharmacists can deliver through practice-based commissioning (PBC).
Potential for innovation
The Improvement Foundation, which supports public services to make measurable and sustainable improvements, feels there is huge potential for pharmacists to develop their services and contribute to service redesign in primary care.
Tim Jones, an NHS Commissioning Specialist, said there had never been a better time for healthcare professionals to be developing innovative services and offering them to the NHS. He said that, because of their locally based premises, pharmacists could provide Medicines Use Reviews (MURs) for patients discharged from hospital, were ideally placed to play a role in addressing health inequalities, and could help commissioners provide care closer to home and meet the 18-week waiting target.
There were opportunities for pharmacists to innovate. According to Mr Jones, commissioners in Milton Keynes had considered a plan for pharmacists to employ GPs and provide a virtual practice for people in residential care under an SPMS (Specialist Provider Medical Services) contract. "There would be no reason why pharmacists could not provide that practice with GPs providing care," he said.
Service redesign was a way of improving services and commissioners were not so much interested in particular professions as finding good-quality providers, he added.
Gianpiero Celino, director of Webstar Health, a provider of consulting and research in health services development, said PBC was important and pharmacists should be "doing something".
But he said the main obstacle to pharmacists becoming involved in PBC was that, although they worked side by side with GPs providing day-to-day services for patients, they had not formed a relationship with GPs and the two professions did not have a track record of working together.
Yet there were good reasons for collaborating, because GPs were influential stakeholders in the deployment of primary care resources, and pharmacists had a huge estate and could provide services within that infrastructure.
In reality, he added, pharmacists were unlikely to become PBC providers but they could work with practices providing minor illness services, MURs and public health services.
Mr Celino said pharmacists had the potential to play a role in the care of patients with diabetes, skin conditions and rheumatism; they could prescribe and could help prevent avoidable hospital admissions and provide follow-up care.
Pharmacists had a unique knowledge of patients and how they used their medicines because they came into contact with patients at the point where they collected their medicines. Patients often told pharmacists things they did not tell their healthcare professionals, and pharmacists had a huge role to play in preventing waste when patients did not take the medicines they had been prescribed.
The new pharmacy contract had brought unprecedented investment in pharmacy premises, which were now open for longer hours. The contract had also introduced repeat dispensing, an electronic prescription service and MURs.
Pharmacists had a business background so were familiar with setting up new services, the private sector and competition. The question for pharmacists was: should they work "for" or "with" GPs?
Pharmacists could provide services that would take capacity from GPs, giving them time to do other things – this was not something for GPs to be ashamed of, he said.
Towards a new relationship?
But there were obstacles for pharmacists to overcome. Recent research to evaluate the new community pharmacy contract found that 80% of community pharmacists felt the new pharmacy contract had not changed their relationship with GPs.(1,2). The introduction of the MUR had not improved communication either, the research found, because it was a paper-based exercise with little face-to-face contact.
Many pharmacists felt that they were not respected by GPs and said they felt greater affinity with their primary care organisation than their local surgeries.
Mr Celino said the only way pharmacists could change their relationship with GPs was by interacting with them on a personal level. He advised: "Over the next few years, you need to be developing trust and building up relationships with GPs. On top of that, you need to develop some strong local networks in order to engage with other professionals and other managed services, the local movers and shakers."
GP Dr Shane Gordon, Chief Executive of Colchester PBC Group and East of England Lead for the PBC Federation, said GPs did not need to worry about pharmacists taking away their work and income.
"The reality is there is a huge demographic burden bearing down on all of us like a runaway train, and if we don't provide community services and go the extra mile, the whole system will break – there is no shortage of work for anybody," he said.
For GP surgeries overloaded with patients – particularly those with long-term conditions – practice-based commissioners should be thinking about how they could link up with other partners in the community to provide holistic services, said Dr Gordon.
He said that his practice in Tiptree, Essex was working successfully with local pharmacists who were conducting MURs for chronic obstructive pulmonary disease (COPD) patients, taking 40% of the COPD work away from the surgery.
GPs now only dealt with the more complex patients.
"Most MURs are well patients I have already seen, and they take up valuable time. Pharmacists can do this without any bureaucracy, as it doesn't need an application through the PCT. I just had a chat with my pharmacist across the road and he said 'yes, I can do that for you'," said Dr Gordon.
He added that pharmacists could start providing some of the diagnostic services in the community as envisaged in the Darzi Next Stage review, could offer telecare solutions for monitoring long-term conditions, and provide minor illness services. They could provide near patient testing, proactive screening for diabetes, cholesterol screening and take blood-pressure readings and send them in to GPs. Doctors could provide signed forms so that pharmacists could do blood tests on patients with a family history of heart disease who fulfilled pre-agreed criteria.
Michelle Webster, National PBC Lead for the Improvement Foundation, acknowledges that there may be suspicions on the part of both GPs and pharmacists about working together.
"That was the main reason for bringing these groups together at a learning event," she explained.
Until now, the Improvement Foundation has been working predominantly with GPs on PBC, but is now keen to see commissioners utilising not just pharmacists but social services, optometrists, dentists and other groups in the care pathway.
Ms Webster said: "There is some worry and suspicion about pharmacists on the part of some GPs. But what needs to happen is for GPs to let go of some areas of their current work so that they can have more time to develop other areas that need their skills.
"There are also many GPs saying: 'If only pharmacists came and talked to us, there are quite a few areas that we would happily hand over.' The two groups are not communicating as much as we would like at the moment."
Ms Webster believes that practice managers have a key role in developing new relationships with pharmacists because, she says, they are the resource investigators of the practice and are
She has experience of this, having worked as a practice manager herself in Sheffield before taking up her current role with the Improvement Foundation.
"Practice managers need to find out what is happening in the community. It's about looking outwards. They are very important in terms of pulling together patients and public opinion and interpreting information," she said.
"In terms of developing new relationships with pharmacists, I would encourage practice managers to look outwards from their practice and into the community."
She added that when considering care in the community, commissioners should be looking at everything that is in place in the community – what buildings there are and who works in them, and start a dialogue.
Pharmacists are not normally consulted, said Ms Webster, and she believes it is time everyone should gather around the discussion table in order for commissioners to gain a broader picture of how services can best be delivered in the community.
"We very much want to concentrate on service redesign of care pathways regardless of profession – it's a question of who is best placed to deliver that care. The point is, it's not about professional groups or carving out services for a particular profession but how we go about achieving the best outcomes for the patient," said Ms Webster.
The PBC and Pharmacy Learning Event was held in North Gatwick in February. It was organised by the Improvement Foundation with support from the South East Coast Strategic Health Authority and local pharmaceutical committees for Kent
1. Blenkinsopp A, Bond C, Celino G, Inch J, Gray N. National e of the new Community Pharmacy Contract. London: Pharmacy Practice Research Trust; 2007. Available from: http://www.pprt.org/Documents/Publications/National_evaluation_of_the_ne...
2. Blenkinsopp A, Bond C, Celino G, Inch J, Gray N. The new community pharmacy contractual framework: effects on integration into primary care. British Pharmaceutical Conference 2007. Available from: http://www.healthlinks-events-bpc2007.co.uk/Bond2.pdf