Duncan McRobbie: I can look at patients’ medication as a whole |
A hospital pharmacist has gone out into the community to run a clinic
for patients with chronic heart disease, bucking the trend of developing
the role of community and primary care pharmacists to offer additional
services.
Duncan McRobbie, principal clinical pharmacist at Guy’s and St
Thomas’ NHS Hospital Trust in South London, spends one session
a week at a GP practice in Clapham where he reviews the medication of
patients with coronary heart disease.
This chronic disease management initiative, which involves three pharmacists,
developed following a successful anticoagulant clinic the team had already
established at the Manor Health Centre.
The pharmacists are paid by the practice out of the budget it was given
three years ago when it became a Personal Medical Services (PMS) practice,
which allows the GPs to develop their own local NHS contract.
The pharmacists offer 20-minute appointments to eight patients every
week who are on the practice CHD register. They review the medication,
working to guidelines agreed with the GPs and one of the hospital cardiologists.
They also look at secondary prevention, which includes asking whether
patients are taking aspirin and checking their cholesterol level.
Mr McRobbie, who is also lead cardiac pharmacist at Guy’s and St
Thomas’, said: “We work to the same guidelines which apply
to the cardiology department at the hospital.”
Changing medication
If the pharmacist wants to change the medication following the review,
a prescription is written by the pharmacist but approved and signed
by the GP. However the pharmacy team is in the process of becoming
supplementary prescribers and once they have all registered and care
management plans have been agreed they will have the power to authorise
medication changes themselves.
Patients have appreciated the specialist care the pharmacists can offer
and only occasionally have expressed concern about not being seen by
a GP.
Mr McRobbie said: “Patients are used to seeking advice from their
GP when they want to. This service is different because they come to
us and see us when there may not be any trouble at all. We talk about
the service in terms of offering them a six monthly or annual MOT.”
GPs and patients have both benefited from the pharmacist-led clinic because
of the specialist knowledge that Mr McRobbie and his team bring, according
to GP Tom Wrigley who is involved in the scheme. He said other PMS practices
could follow their example although practices which are still tied to
the national General Medical Services (GMS) contract could approach their
primary care trust to introduce a trust-wide scheme instead.
He said: “The pharmacists have a fantastic amount of knowledge,
particularly as far as prescribing is concerned. They are taking a lot
of work away from us and are able to do certain things much better than
we can.
“They do a lot around medicines review and also make sure that we
are doing things appropriately — they keep us on our toes. The patients
also appreciate the service because it is quite unusual today, in the
present climate of ‘fire fighting’, for patients to be invited
in. A lot of patients with CHD are elderly and they like the idea that
people are taking an interest in them.” Pharmacist vs GP
There are definite patient advantages for the service being offered
by hospital pharmacists rather than GPs, according to Mr McRobbie.
He said: “We have to look at the patient’s cardiac medicine,
but we also have to look at their other medicines, such as what they
are taking for diabetes or urinary incontinence, and see that their cardiac
medicines fit in with those.”
He said that GPs were sometimes reluctant to change consultant prescriptions
but hospital pharmacists knew that consultants would often start patients
on certain medication when they left hospital with the expectation that
changes would be made later.
Mr McRobbie also argued patients benefit from his dual role because he
has access to hospital clinics. “The problems with communication
between hospital and primary care works both ways. But if I see a patient
in the practice who has just left hospital or who has been at outpatients
I can, if necessary, easily pick up the phone and talk to somebody. I
also have the opportunity to refer people in to hospital, if necessary,
to the heart failure clinic.” Pharmacist vs specialist nurse
His extensive medicines knowledge also gives him an advantage over
specialist nurses who run CHD or other chronic disease management clinics,
he
believes. He said: “Specialist nurses do specialist things — patients
may see one nurse about their asthma, another about their diabetes
and another about their heart disease. But I can look at a patient’s
medication as a whole whereas a specialist nurse may know a lot about
a small number of medicines.” Hospital vs community pharmacist
He is confident that as a specialist cardiac pharmacist he has the
professional edge over a community pharmacist who may be encouraged to
provide a
similar chronic disease management service.
He said: “I think the fact that I am a specialist trained cardiac
pharmacist means that I can bring a lot more [to the role] than if I
were a community pharmacist doing a medicines review who has a lot of
general medicines knowledge.”
The initiative has the support of the hospital pharmacy department and
the hospital cardiologists. Mr McRobbie said: “It is seen as an
important role for the continuation of care. I think what is interesting
here is that a GP may have 4 per cent of his patients taking CHD medicines
but that is 100 per cent of my job. I am totally familiar with that patient
group.” |
The
Pharmaceutical Journal