Medicines Management
Issue no 1, pp14
January/February 2002

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Features

How to organise "PAPs" for all

North Birmingham primary care group currently has a practice-attached pharmacist (PAP) in 69 per cent of its GP practices and plans to cover them all. The current model is for a pharmacist to be based in a particular practice one day a week for larger practices and half a day for smaller ones. PAPs are based at practice premises not the PCG offices so that they are hands-on rather than just visiting and making recommendations.

Why use this model?

Having a regular PAP means that the practices get to know the pharmacist and vice versa. Practice staff are more likely to come and ask questions and the PAP will learn the most appropriate member to approach to make sure things are done. PAPs will also learn how to use the GP computer systems more effectively as time goes on.

Projects can be carried out, reviewed and re-audited since the PAP will still be there six months later to collect and analyse the data. Problems will be picked up by being in situ; eg, while on one project, you will nearly always spot others that can be done.

It is important to be able to work in a team and liaise with all practice staff. PAPs need to be self-motivated. They need to recognise problems on their own and act on them. All the PAPs have either completed or are doing a clinical diploma. This helps them better identify areas where the prescribing can be improved and gives them confidence. Diploma projects can be based on a practice's patients and therefore help the GPs' prescribing.

What PAPs can do for practices

Obviously PAPs who work in practices that are overspent will look at cost issues (eg, by doing PPI reviews and looking at high cost areas), but that is not their sole purpose. Two practices have had PAPs for six years, so have already "cut-off the fat" and are more involved in quality issues, including the NSFs. Examples include reducing benzodiazepine prescribing, medication review in the elderly and ensuring statins are given to those at risk.

Are PAPs appreciated by practices?

Many GPs do not want to be without them. Those that have previously had PAPs are nagging for another to join them. Today, a practice manager told me that their PAP had really fitted in with the practice, saved them lots of money and is missed. Practice nurses also use PAPs for many queries — and not just about vaccines and asthma.

What projects are PAPs doing?

They are working on prescribing incentive schemes and personal medical service pilot issues plus others that ePACT or the practice might highlight. Some are listed below:

PPI prescribing audits; reducing hypnotic and benzodiazepine prescribing; helping GPs keep to the antibiotic formulary; statin audits; monitoring long-term steroid use – preventing osteoporosis; nursing home reviews; improving the practice review system; asthma revision with practice nurses; increasing levels of generic prescribing; and distributing leaflets to patients with GI disease.

For example, prescribing of hypnotics has been reduced by a third in one practice. In another, patients fill in a form about their medicines before they see their GP for a medication review. Now 96 per cent of practices have generic prescribing levels above 72 per cent.

What PAPs say about the work

"It's fulfilling when a practice actually carries out some of the recommendations you've made. It's quite exciting when you can actually see some of the prescribing costs fall after you have made a change! It beats counting tablets!"

"It's satisfying to make a difference. It's a job that gives me the opportunity to use my clinical knowledge and organisational skills daily."

What PCG support is given to PAPs?

PAPs meet once a month and are all able to communicate by email. Every month, a summary of everyone's activities is circulated to share ideas. The PAPs all attend the National Prescribing Centre study days to keep up-to-date with the latest evidence-based medicine.

Is it expensive for the PCG?

Yes it is, but at the same time, the Government requires PCGs to meet NSF targets and improve the quality of prescribing. The PCG can be ahead of the game, for example, medication reviews in nursing homes are already taking place. Practices have more and more pressure to improve the quality of their prescribing and this takes time. A PAP is an indication that the PCG is supporting the extra work that improving prescribing will bring.