Primary Care Pharmacy November 1999 Vol 1 No 1 p18-19
Medical view
A general practitioner perspective
By Sheena Macgregor, MRPharmS
A former senior partner in a group practice which took on a practice pharmacist gives his views
General practitioners are beginning to realise that the inclusion of a pharmacist in the team can result in benefits to patients and other team members. I asked Dr James Dunbar, until recently senior partner at Downfield surgery, Dundee, what he expected when a pharmacist joined the surgery–based team. Why did the GPs in the practice decide to invite a pharmacist onto their team?The practice drug budget was comparable to that of a small local hospital where five pharmacists provided clinical input. We decided that there must be scope for similar input at a primary care level and became involved in a research funded project to assess this. We quickly realised that there were many opportunities where pharmacists could contribute to the multidisciplinary team and that their skills were a useful addition for staff and patients. |
Downfield surgery: took on a practice pharmacist |
Can you highlight areas where pharmacists have a positive role to play?
Pharmacists have shown that they can contribute to a wide range of activities in primary care. Not only can they improve quality of prescribing through formulary management and therapeutic substitution, saving their own salaries in the process, but they have a major role to play in the implementation of national evidence-based guidelines which also improve the quality of patient care. A pharmacist can take a guideline and negotiate a practice protocol, identifying the role of all primary care team members and the contribution from secondary care. Training and information technology needs can be identified and following implementation they can audit the quality of the care, providing the necessary feedback to the team.
Review of existing patients already receiving treatment is also essential to implement a guideline fully. How many GPs have the time to dedicate themselves to that? But, delegate the task to a pharmacist who can review the patients on a one-to-one basis and who only comes back to you with clinical issues out with the implementation protocol, or because he has identified an unrelated pharmaceutical care issue, and you can maximise evidence-based care to the whole practice population with very little extra GP input.
What effect has this had on the drug budget?
A combination of formulary development with regular review, increasing generic prescribing appropriately, and medication review in specific therapeutic categories, has reduced prescribing costs substantially. The discussions made the whole team more critically aware of their prescribing practices, which was beneficial in itself and led to optimisation of existing resources so that we could increase expenditure where new evidence indicates improved quality of life and health gain for patients.
Do you believe this had benefits for patient care?
Yes. Take anticoagulant management for example. Audit shows the care of this group of patients has improved substantially since being taken over by a pharmacist based at the surgery, with INRs more consistently within the target range than before. Similarly, the introduction of a pharmacist pain clinic reduced patient waiting time from 42 weeks to 2 weeks, with outcomes as good as those of the hospital pain clinic, and with more time spent in helping patients to have realistic expectations of the therapy prescribed. Helicobacter eradication resulted in letters from grateful patients who had suffered most of their adult life from ulcer related pain. And we also have better educated patients who are more able to make informed choices with regard to their own treatment, something that cannot always be achieved during a short GP appointment.
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New patient services have been introduced |
Is there a role for pharmacists to manage patient clinics?
In some areas of chronic disease management the pharmacists' skills make them the most appropriate health care professional to run the clinics. This is particularly appropriate where patient concordance with medication is essential to achieve the required health care outcomes, as in Helicobacter eradication, where drug regimes are complex, have unpleasant side effects, require careful monitoring and dosage titration, or where the patient needs to be well informed, for example, in anticoagulated patients. It is also appropriate where the effects of interacting medicines or concurrent diseases will influence the choice and dose of medicine required. Repeat medication review, particularly in the elderly population, resulted in reduction of polypharmacy in a vulnerable group and initiated nurse monitoring for drug-related adverse effects.
Did you or your partners ever feel threatened by having a pharmacist in the team?
Admittedly there was some initial reticence. There was some concern about having our prescribing scrutinised, but we soon realised that when pharmacists are part of the team they are aiming for the same outcome, namely, improvement in patient care. We see some aspects differently but peer review leads to overall team improvement. A genuine team approach combined with a readiness to try new ideas leads to a system of care which encourages innovation and development.
Some GPs also worry about deskilling if they delegate their more traditional roles to other team members, but in the practice our view has been to get the diagnosis right so that the team could then provide the appropriate treatment. It also allows GPs to undertake the new roles and opportunities that arise as a result of increased primary care management.
Would you recommend the experience to others?
Yes. Improving the service to patients does not have to mean more work for GPs. Pharmacists can take on the time consuming aspects of protocol development, review of patient case notes, and explaining medication changes and why they are appropriate to patients, all essential components in achieving high quality cost effective patient care, but which would be impossibly time consuming for the already stretched GP. Add to that someone who can handle the team's drug information needs, review new drugs and clinical trial information, provide information leaflets for patients, deal with queries from community pharmacists, receptionists and patients themselves and who solves the interface issues that occur when patients are discharged from hospital and I think you have a useful addition to the team who saves GP time rather than impinging on it.
How do patients react to a pharmacist managing their care?
Patients prefer the familiarity and convenience of services within the surgery wherever possible. Survey of patients who have had contact with the pharmacist indicated they were generally unconcerned about who managed their care as long as the person was competent to undertake the job. Most also commented that they appreciated having a medication review and would welcome it more often.
And the future?
Primary care trusts and primary care groups need to encourage GPs, prescribing advisers, practice and community pharmacists to work together to achieve quality, cost-effective prescribing. The level of pharmacist input depends on the objectives and strategies of the individual PCT or PCG, but the pharmacist's contribution in providing advice and practical support to the primary health care team cannot be ignored if drug budgets are to be managed effectively and patient care maximised.
Miss Macgregor is senior prescribing adviser, Borders primary care trust and editor of Primary Care Pharmacy