Primary Care Pharmacy November 1999 Vol 1 No 1 p14-15

In the surgery

The role of the full-time practice pharmacist

By Marian Bradley, MRPharmS

It means belonging to the practice in the same way as a practice nurse

The practice pharmacist role, as I see it, is a logical extension of hospital clinical pharmacy or ward pharmacy (call it what you will) into primary care.1 Thus the pharmacist, up on the ward and freed from the dispensing bench, can have a direct input into the prescribing process and help doctors, nurses, other health professionals and especially patients with all aspects of drug therapy. One of these aspects is helping to comply with the hospital formulary. In a similar way, my objectives at the practice are to promote rational prescribing and evidence-based medicine, improve the pharmaceutical care of our patients and manage the practice's drugs budget. In doing so I save time for everyone in the practice and help to contain the rising cost of prescribing. This involves completely shedding the dispensing and supply function and I like to explain to our patients that a practice pharmacist does not supply drugs but helps doctors and patients with all aspects of prescribing and taking medicines. I prefer the term "practice pharmacist" rather than the non-specific "primary care pharmacist" to describe the fact that I belong to the practice in the same way as a practice nurse. The main difference is that the practice nurse is 70 percent funded by the health authority, and there is no equivalent standard mechanism for funding practice pharmacists. Up to now they have been variously funded from fundholding savings, top-slicing the drugs budget, management allowances, etc. Some health authorities have funded them directly as a response to the need to address rapidly rising prescribing costs.2 It seems that clinical pharmacy in secondary care is an "add-on" to the necessary supply function, and clinical pharmacy in primary care is an "add-on" to the necessary cost-saving function.

Discussing medication queries with patients

Advice is frequently given by telephone

Roles of a practice pharmacist

Practice pharmacists respond to the differing needs of their practices; however the roles may be split into the following three categories: administrative, clinical and interface. The various functions under these headings are listed in the table.

Table: Roles of the practice pharmacist
Administrative Formulary Development Maintenance Computerisation Managing drug budget PACT data High cost drugs New drugs "Fine-tuning" prescribing Practice computer "house-keeping" Repeat prescribing protocol development maintenance	Clinical Patient education and counselling Drug information doctors other health professions Domiciliary visits monitoring drug therapy and Adverse Drug Reactions Nursing/residential homes Research and audit clinics (eg, anticoagulant) Liaison "high tech" and other patients community pharmacists Health Authority advisers and other health professionals pharmaceutical industry	Interface Area prescribing committee Liaison with hospital prescribers pharmacists specialist nurses Discharge and Out patient prescription requests

I consider myself privileged to have been able to work as a full-time practice pharmacist for nearly five years, from 1994 to the advent of primary care groups. The anticoagulant clinic which I run is taking up more and more of my time as so many patients are being prescribed warfarin for stroke prevention in the presence of atrial fibrillation. It is also used by the local vascular surgeons, and, of course, the population is ageing. The local hospital is also having trouble coping with so many anticoagulated patients. Now the health authority is investigating the possibility of more primary care clinics. I am involved with these discussions and I hope the position of pharmacists will be considered. I believe pharmacists are the best health professionals for running warfarin clinics.
I am closely involved with what I term "high tech" patients, or those being monitored by secondary care and who have high prescription needs, especially transplant, dialysis and cystic fibrosis patients. They know that if they telephone me because their medication changes I will be able to transcribe it correctly onto the computerised prescription. If it is wrong then everyone gets hassled – patients, pharmacists and doctors. I am also frequently asked by patients, carers, district and Macmillan nurses for prescriptions for terminal care items. Again, these are for patients with high prescription requirements and as well as a prescription they also get advice. The partners frequently telephone me from patients' homes with requests for help with prescribing drugs for syringe drivers.
I do all the repeat prescriptions for nursing and residential homes. I try to gradually wean patients off phenothiazines and hypnotics and save money by not automatically prescribing items such as creams, inhalers and dressings every month. I try to help the supplying pharmacists as much as possible having worked in community pharmacy I know the pressures they are under.
As a practice we see one industry representative per week which is a good opportunity to discuss new drugs together. I do get targetted individually as a result, which can be time-consuming but at least it frees up the partners' time. Much of my time is spent on the telephone to patients, or seeing them when they call in with their queries about drugs. The receptionists are grateful that I am on the spot for instant advice, otherwise they would have to wait for a doctor to appear and call the patient back. A recent initiative in conjunction with the receptionists and my community pharmacist colleagues was changing to salbutamol CFC-free inhalers. The change seems to have been accomplished surprisingly smoothly.

The future

All good things come to an end, and with the demise of fundholding my job has changed considerably.
In the meantime, I am somewhat disappointed that my clinical role is being overshadowed by the need to help PCGs stay within budget. This is a step backwards. While pharmacists are becoming more educated for the role by undertaking clinical diplomas (essential at the moment, to enable, at least the older pharmacist, to work in GP surgeries) they are being denied the opportunity for direct patient care. As I queue up outside the doctor's consulting room for a signature for yet another prescription for warfarin I wonder whether I will ever live to see the day I am allowed to sign one myself.

References

1. Wells WDE. Pharmacists are key members of primary health care teams. Br Med J 1997;314:1486. [Medline reference]

2. Doran K. Prescriber support pharmacists in primary care. Pharmacy Management 1997;13:49-51.

Mrs Bradley is practice pharmacist at Northgate Medical Centre, Walsall