Primary Care Pharmacy November 1999 Vol 1 No 1 p3-5

In the beginning

Opportunities for pharmacists in primary care

By Pamela Mason PhD, MRPharmS

How a new breed of practitioner has evolved over the past 10 years

Over the past 10 years, a new and exciting role has emerged for pharmacists. Labelled in various ways as a "prescribing adviser", a "prescribing support pharmacist", a "GP pharmacist" or a "primary care pharmacist", the individual works within a GP practice or health centre.1 The establishment of primary care groups (PCGs) in England and their equivalents in Wales and Scotland – local health groups (LHGs) and local health care co-operatives (LHCCs) – is creating even greater opportunity for pharmacists to work in GP practices. Indeed, few and far between are the weeks when The Pharmaceutical Journal does not carry advertisements for this new "breed" of pharmacist, and between the end of June and the end of September this year there were more than 40 such posts advertised. In terms of need, however, these advertisements may represent only the tip of the iceberg, with many other posts being filled informally at local level. The number of pharmacists working in GP practices is therefore unknown. Currently, the main driver for the growth in this role is the prescribing budget. PCGs have been charged with a responsibility for improving the health of the community, developing primary and community health services and commissioning secondary care services, all within a cash limited unified budget. They therefore need to manage costs carefully. And with GP drug expenditure (in England) accounting for approximately £4.5bn each year – which represents about 50 per cent of costs in primary care – prescribing is high on the PCG agenda. Cash limited prescribing budgets apply to all practices, and despite the fact that good prescribing practice has been established in many general practices, there is growing concern as to the ability to stay within budget, particularly during the next few years. Pharmacists working in medical practices will therefore have an important job to do. So what exactly are the opportunities, and what type of working arrangements are already in existence?

Primary care work involves an educational role

Working models

Until recently, prescribing advice and support was provided mainly by pharmaceutical and medical advisers, although there is now a need for greater local support than that which can be provided by the health authorities and health boards. In addition, GPs often prefer to employ someone of their own choice, whom they perceive to be independent.
Pharmacists already working in general practices are employed according to a variety of different arrangements. Thus, some pharmacists are employed directly by a GP practice on a full time, part time or sessional basis, some are employed by a health authority or health board, others are seconded by a local trust, academic unit or community pharmacy, while others work on a consultancy basis. In an attempt to clarify this confusing and ill-defined picture, Jesson and Wilson¹ have recently suggested that a model for the pharmacist working in a medical practice could be defined according to five distinct levels:
1. Educational outreach The pharmacist is trained to visit surgeries to deliver a key message (similar to a drug company representative) to about 20-25 practices
2. Sessional target A development of level one, in which the pharmacist delivers key messages, but visits a surgery more than once.
3. Consultancy The pharmacist is based in the practice on a temporary basis
4. Primary care pharmacist The pharmacist is based full or part-time in the practice
5. Health centre pharmacy and pharmacist The pharmacy is relocated into a health centre and the pharmacist works there on a permanent basis, combining the traditional supply role with the activities of a primary care pharmacist
All these models are currently in existence, but it seems likely that, as more GPs experience the valuable services that a pharmacist can provide, and PCGs merge and become larger, more pharmacists will be needed on a permanent basis. In other words, of the above models, numbers four and five could become the most common. And, as PCGs gradually become trusts, there could be also a return to something similar to the old district health authority model with a trust chief pharmacist and pharmacists employed within individual practices.

Activities

When pharmacists first started working with GPs, analysis of prescribing data tended to be one of the main activities and, as a result, pharmacists have been successful in improving prescribing quality and reducing costs by encouraging a shift to less expensive drugs that do the job as well, if not better. Typical examples include generic substitution, increased emphasis on thiazides and beta-blockers as main line therapy for hypertension and appropriate use of steroids and beta-agonists in asthma. This work was fairly straightforward and involved encouraging prescribers to accept well-established evidence-based practice.
With the advent of PCGs, however, pharmacists can play an increasingly strategic role. Whether members of PCG boards or not, pharmacists can provide strategic and tactical prescribing advice, contributing to the development of prescribing policy across the PCG. At an operational level, pharmacists can work with GPs and practice staff to improve the quality and cost effectiveness of prescribing and to help implement PCG board recommendations and policies. Activities to improve cost effective prescribing may include not only analysis of prescribing data, but also review of repeat prescribing systems, review of repeat prescriptions and formulary development and maintenance.
A natural progression from formulary work is the development and implementation of guidelines and protocols. This is likely to become more important with the work of the National Institute for Clinical Effectiveness (NICE) as national recommendations will need local interpretation and implementation. And with the potential for an increasing variety of health professionals involved in prescribing, including nurses and pharmacists, co-ordination and monitoring of prescribing and development of protocols for all professionals will be vital.
In addition, many prescribing issues span primary and secondary care, with medicine use and policies in one sector affecting those in the other. These issues will be common to all practices in a locality, and it is often beneficial to develop prescribing policies and protocols locally. These policies can include developing areas of commonality between community and hospital formularies and reviewing discharge and admission policies.
Pharmacists can also make a valuable contribution to the management of the practice computer system. The majority of GPs now use computers for prescribing, but there are several problems with these, including too many drug choices on the database, lack of a standardised approach to identification of generic names and delays before new drugs, new prices and Drug Tariff changes appear. Customisation of the software to the practice needs can simplify prescribing and reduce errors, improve adherence to the practice formulary and make prescribing more cost effective.
Another role for pharmacists in GP practices is working at the individual patient level, using either the classic pharmaceutical care model^2,3 or the medicines management model.⁴ This involves review of patients' medication, ensuring that this is appropriate, effective and safe and that the patient is using his or her medicines properly. Several pharmacists have established clinics in GP practices for this purpose (eg, anticoagulant, pain, migraine, asthma and diabetes clinics), but this activity can – and should – also take place in a community pharmacy as well as in patients' homes, including residential and nursing homes. Medication review can be particularly useful in nursing homes because of the number of people on complex drug regimens. In addition, streamlining systems in homes for re-ordering medication can achieve savings in terms of time, waste and resources, and is something which should be done in collaboration with local community pharmacists.

Skills

Pharmacists with a wide variety of backgrounds – community pharmacists, hospital pharmacists, health authority pharmaceutical advisers and independent pharmacy consultants – are working in medical practices, and all bring different skills.
Community pharmacists bring business skills, such as planning and target setting, and they are used to working within budgets. In addition, they have particular expertise on the costs and use of drugs in primary care. And, having access to people in the locality, including those who are healthy as well as those who are sick, community pharmacists have a unique perspective which means that they can provide invaluable information on health care needs and public health. Moreover, with their traditional role in giving informal advice to large numbers of people, community pharmacists have a good understanding of the patients' view of medicines.
Hospital pharmacists may bring better clinical skills than the community pharmacist, simply because of the environment in which they work. In addition, a hospital pharmacist may have particular skills in working on prescribing issues and guidelines that are applicable across the primary/secondary care interface. Both "hospital-led" and "GP-led" prescribing issues can be more effectively resolved without confrontation, and this encourages the delivery of advice and support in both settings that is consistent and cohesive.
What is probably more important than previous background, however, is the individual pharmacist's skills and experience, and there is some indication currently that medical practices are having difficulty in recruiting pharmacists with the right skills. Clinical skills are necessary – of course – but because some GPs may not have had experience of working with a pharmacist before, "people skills" are particularly vital, and pharmacists need an ability to build long-lasting and good relationships within the primary health care team. And what is needed above all is the ability to be able to manage and influence change.
There is a need to be able to work both as an independent professional and also with many other professionals, and assertiveness, authority and good communication skills are essential to cope with this. Knowing and respecting the variable cultural identities and attitudes of National Health Service personnel and being able to develop constructive working relationships with such a diverse group of people are important.
In addition, it is necessary to have a grasp of strategic and operational planning and an ability to be able to interpret health authority and PCG strategy relating to prescribing issues as well as an understanding of public health and epidemiology. An understanding of the influences on prescribing – both medical and non-medical – and the differences between primary and secondary care hierarchy and structure are also important.
At the prescribing support level, the ability to analyse and interpret prescribing data will remain important but in the future, will not be enough. This is because a key issue for PCGs is that of forward planning. Data supplied by prescribing analysis are based on past prescribing and the emphasis in PCGs will increasingly be on being pro-active instead of merely following general historical trends. Thus, if there is a change in PCG prescribing policy, the effects of this will need to be evaluated rapidly. Clinical skills alone are not enough to enable data collection and organisation with a view to analysing outcomes. This will call for more advanced skills, including an ability to use spread sheets and data bases.
Moreover, there will be an increasingly epidemiological aspect to prescribing choices, focusing on which patients to treat in addition to the drugs that should be used to treat them. Thus, there will be a strong emphasis on targeting of therapies at high-risk patient groups rather than the choice of drugs per se.
Clinical knowledge needs to cover not only an understanding of drugs, how they work, what they cost and how they are used, but also broader skills, particularly critical appraisal. There is a need to acquire and apply clinical knowledge to support cost effective service developments in areas as diverse as the management of asthma and diabetes by GPs and practice nurses, home parenteral nutrition and palliative services in oncology patients. The ability to assess, develop and apply health economic evaluations in a variety of clinical situations is also important as are skills in the collection, analysis and presentation of scientific information, and in interpreting advice from elsewhere.
Much of the work of a pharmacist in primary care involves playing an educational role and an ability to teach people of varying ability in different situations is important – from a "one-to-one" basis where the aim, say, is to shift a doctor's prescribing, to managing and addressing large meetings.

Conclusion

Pharmacists have been working in GP practices for more than a decade, but the development of PCGs is providing the profession with huge number of new opportunities to become more valued members of the primary health care team. Working as part of the "bigger picture" in a multidisciplinary team, pharmacists can make an important contribution to health gain. Short on resources, particularly time, GPs need prescribing and other support related to medicine use, and pharmacists can give this, enabling doctors to free up time to make more effective use of their own skills and concentrate on other areas of patient care. In terms of outcomes, pharmacists should be able to contribute to effective management of the prescribing budget, improve the efficiency of the prescribing process, implement, monitor and review prescribing policies and clinical guidelines, make prescribing increasingly evidence based, bringing care of patients in line with best practice and also involve community pharmacists in the development of new services. This will help PCGs to achieve their targets in relation to the health improvement programme, clinical governance and costs. And most importantly, it should enhance patient care.

Pharmacists can make an important contribution to a multidisciplinary team

References

Pamela Mason is a pharmacist and freelance writer from Sydenham, South East London.