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Wednesday 26 October 2016
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Sticking to the script

Integrating a pharmacist is fast becoming a key way to develop the GP surgery in the primary care led agenda 

At DMC Healthcare in our GP surgeries we have employed pharmacists for many years and they have now become instrumental in supporting the doctors and primary healthcare team (PHCT) in numerous clinical and administrative issues and over the last three years, even more so supporting key components within the group medical services (GMS), personal medical services (PMS) contracts, departmental and local enhanced service schemes and now care plans within the unplanned admissions programme.

Their workload fits into the current and future NHS expectations as we try to support patients with long-term conditions, delivered and monitored in primary care and where possible, remove the on going need for secondary care interaction and release some pressure on A&E and urgent care facilities such as out of hours (OOH).

The facts
Let us examine some key facts that will not change or indeed go away, with an ever-increasing ageing population.

Fifty five per cent of consultations undertaken at the GP surgery are from patients with chronic medical conditions, on average, some 6% of any registered population.

Research indicates that at least 8% of patient contacts could be managed within primary care, by adopting a more in house team model approach as in our case with the inclusion of the pharmacist within the primary health care team.

Avoidable medicines wastage in primary care through non-adherence, changes in prescribing and changes in the patient’s clinical condition are estimated to cost some £150 million per year and certainly will continue to grow.

Patients not taking their medicines correctly can lead to drug related issues and increased hospital admissions up to 15.4% per year. Medicine management is therefore a key issue to address in terms of patient guidance, compliance, safety and associated cost. All our practices use electronic prescribing services.

The largest support area and slice of the primary care cake is that between15-20% of GP workload can be transferred to pharmacists within the practice environment, providing a national annual cost saving to the NHS purse of some £2 billion.
It is crucial for general practice to have, as the expected future lead in primary care development, all the necessary triggers and clinical support to delivering healthcare to the patient population, within a cohesive practice based environment and the role of the practice based pharmacist we find has become crucial within this framework.
We have concentrated our efforts in four key clinical work streams:

  • Effective patient and quality prescribing.
  • Chronic and long-term patient conditions – care plans and reporting.
  • Patient appointments and access support.
  • Patient self-health promotion, awareness and wellbeing.

Our pharmacists manage all the above extremely well and are prescribers for medicine management and pivotal in supporting patients in primary care.
Patients with long-term conditions have a reduced quality of life and require significantly longer stays in hospital. It is estimated that 70% of NHS spend falls into this category there are 6% of patients who require on going and regular clinical support.
This is expected to rise by a further 25% over the next 20 years!

A crucial role
Our practice based model focuses on offering patients long-term care in the community; the pharmacists provide them within managed conditions without them having to visit the GP every time they need a repeat prescription, or in many cases advice that they can provide on the telephone or indeed in consultation at the surgery itself. No different from the high street but within the surgery and therefore more cohesively recorded, monitored and regulated.

Additional pressure such as the continual move to increase accessibility for surgeries being open from 8am to 8pm and at weekends adds further weight to an already heavy GP workload. Practices often can’t hire GPs who are prepared to work longer hours, at times even with financial incentives, which together with running costs add monetary pressure on GP practices. Pharmacy support provides excellent value for money within this team approach.
Our pharmacists support the over 75 registered at the practice, by coordinating with the patients’ named GPs, again especially on medication and health promotion.

The Health and Wellbeing agenda and challenges are based around key health issues; obesity, sexual health, alcohol, smoking and drug misuse. Council Health and Wellbeing boards with clinical commissioning groups (CCGs), are charged to commission services for an ever aging population, which will increase health care spending by some £1.4 billion per year.

In the community 96% of patients can travel by car or on foot to their GP surgery, our pharmacists are playing a vital role in providing advice and health literature on smoking, sexual health, weight management and substance misuse.
Our pharmacists are supporting this approach within the surgery environment and reporting to GPs and updating our quality and outcomes frameword (QOF) registers in the process.

Future prospects
The prevention arm of pharmacy support is to be explored further during this year and we intend to invite and work more with local Public Health on improving patient education and advise on the patient’s individual lifestyle and general wellbeing, all community focused.

  • Chronic disease management and follow up support, has always been at the cornerstone of general practice. This has vastly increased over the years as GPs struggle to meet demand. It is obvious that the better the community service, the less of the need to require secondary care interventions. Our pharmacists are playing a vital role in supporting this principle and support the GPs with clinics in:
  • Asthma: all asthma annual reviews, diagnosis/assessments, spirometry.
  • Chronic obstructive pulmonary disease (COPD): all COPD annual reviews, COPD diagnosis and assessments, spirometry (including FEV1 test), Medical Research Council (MRC) assessment and oxygen saturation management.
  • Diabetes: diabetes annual reviews – managing all aspects of diabetes and diabetic diagnosis – reviewing blood tests, diabetic foot examinations and assessments, diabetes dietary reviews, erectile dysfunction screening/assessment and treatment.
  • Hypertension/cardiovascular risk: identification, monitoring of patients with high cardiovascular risk, initiation of management/treatment plan for patients with hypertension and high level of lipids.
  • Depression: depression annual/interim reviews.
  • Rheumatology: rheumatology annual reviews, rheumatology pathology requesting and monitoring.
  • Minor ailments: dyspepsia, gastro-oesophageal reflux disease (GORD), constipation, diarrhoea, irritable bowel syndrome, haemorrhoids (piles)
  • Respiratory system: cough, cold, hay fever, upper respiratory tract infections (URTI), chest infections.

All data is at that time transferred to the patient’s notes, supporting fully QOF data updates and assisting GPs so that they can be released for other clinical interventions and more quality time with patients.

Making the dream a reality
I am sure, if we went back to 1948 with the inception of the NHS, in hind sight we would have made sure pharmacists were part of any primary care team and based with us here in a community setting.
With patients living longer and many living alone and secondary care struggling with bed demand, it has to make sense that we explore every avenue to provide and promote a primary care led service, where, clinically possible and financially practicable, patients live in their own homes as long as is possible for them to do so.
For the first time in more than 50 years, it appears all health and social care agencies agree to this strategic approach, as do the politicians. Let’s look forward together.
CCGs are ideally placed with HWBs to commission primary care led services around the patient by way of an integrated care model for patients and removing the need, where practicable for secondary care interventions. The pharmacy role within general practice can help this dream become a reality.

Andrew Kolenda is a primary care management consultant working on primary care development issues for DMC healthcare in south east London.