The idea of clinical pharmacists in general practice is now well under way to becoming established in primary care. The NHS England pilot has helped successfully brand what was already an existing role albeit by another name. When Wakefield CCG decided to design what a local version of clinical pharmacist in general practice would like, we realised that our title should change the word pharmacist to pharmacy. The absence of pharmacy technicians from the national pilot seems to be an oversight. Pharmacy technicians are an untapped resource and need to be part of any clinical pharmacy offer in primary care.
The challenge clinical pharmacy in general practice (CPGP) is attempting to tackle is multifaceted: general practice is facing a challenge on increasing population and workload but a decreasing workforce pool and funding.
The demands of the population are becoming more complex, and as more services undergo 'left-shift' into primary care, the workload on the primary care workforce is reaching unsustainable levels.
CPGP aims to address this by placing clinical pharmacist and pharmacy technicians into GP practices with clearly defined roles and objectives that will help address the aforementioned challenges. Their focus falls into the following categories:
Constrains in funding mean that CPGP is hosted at the federation level, which covers an approximate population size of 50,000 patients and on average is made up of five GP surgeries.
Each federation employs:
The roles of the CPGP team include (but are not limited to) the following:
Clinical Pharmacist:
Risk stratification tools to prioritize patients; level 3 medication reviews; de-prescribing; identifying unmet need; complex queries and target problematic poly-pharmacy patients
Senior Clinical Pharmacy Technician:
Review repeat prescribing processes and policies; implement sustainable solutions to mitigating safety risks associated with prescribing as well as reducing inefficiencies in the system; leading on digital agenda e.g. improve electronic repeat dispensing access and online ordering; post discharge medicines reconciliation; learning & development for practice medicines coordinators; queries
Clinical Pharmacy Technician:
Implement cost-effective changes to meds through pre-approved protocols; queries and support to general practice staff.
NHS Wakefield CCG has successfully completed the pilot phase of CPGP in 2017-2018. The results of this are included in the appendix. The success of the pilot has resulted in CPGP being recommissioned until 2020.
The mechanics of implementing this idea requires engagement between the CCG (medicines optimisation team and clinical leadership at the executive level) and GP federations. GPs know that there workload has to be stratified and more multidisciplinary working is needed. There has to be an acknowledgement from GP federations that there must be investment in a diverse primary care workforce that extends beyond GPs. That means looking at developing pharmacists, technicians, physiotherapists, advanced clinical practitioners and others.
Recruitment of pharmacy staff and training is needed where necessary. Overarching this, there needs to be an interface/leadership role on the project at each federation who can take ownership of activity.
From a financial perspective, CPGP in 2017-2018 was funded by MCP. However, for 2018-2020, a sustainable model has been developed which was key to getting GP federations signed up to the scheme in the short and medium term.
Patients:
Immediately, we know that patients who have complex polypharmacy needs will benefit from having a medication review with a highly skilled clinical pharmacist. Our pilot results showed that 15.5% of medication reviews identified an unmet prescribing need. 35.8% on medication reviews with a clinical pharmacist identified an opportunity to simplify patient's medication regime. 12% of medication reviews identified an inappropriate dose. These are just some of the issues that clinical pharmacists carrying out quality medication reviews have identified.
Patients on repeat medicines will benefit as the efforts of the senior clinical pharmacy technician will seek to improve their access to digital services i.e. electronic repeat dispensing, online ordering and patient online services
Primary Care Staff:
Claiming to save time can be problematic, namely as it is very hard to approve. What CPGP will do is increase capacity. In years 2018-2020, senior clinical pharmacy technicians will aim to boost eRD uptake in suitable patients. The systemic effect of that being a reduction in unnecessary patient contacts with the practice, which will result in a reduction of workload for prescription clerks and GPs. The reviews of repeat prescribing policies and processes also seek to increase capacity by reducing inefficiencies in the process.
Health Economy:
Prescribing budgets are under greater pressure than ever before. By employing clinical pharmacy technicians that are implementing cost-effective changes and initiatives, this will reduce spending. Clinical pharmacists that are deprescribing will also contribute to this. Practices will see a benefit in this cost reduction, especially if budgets are delegated out from the CCG and out to federations at some point in the near future.
Pharmacists & Technicians:
The advent of these new clinical roles is providing a basis for establishing the role of pharmacy in general practice on a permanent basis. The success of schemes like CPGP will have an effect on how pre-registration training, university and college education is designed to take into account this newly established sector in pharmacy.
In 2017-2018 (April 2017 – January 2018), we achieved through cost-effective prescribing changes and medication reviews the following outcomes:
All of this was achieved with almost half of the 21 advertised posts unfilled. In addition, the recruitment was started late and we had staff starting as early as June and as late as October.
KPIs for 2018-2020:
Measurement of KPIs:
Financial resources breakdown:
2017-2018: MCP funding (non-recurrent)
2018-2020:
