Primary Care Pharmacy March 2000 Vol 1 No 2 p35-36

Viewpoint

Primary care pharmacy - past, present and future

By Peter M. Matthews FRPharmS, PGDipPresSci

When I read the Executive Letter and associated Working Paper "Improving Prescribing" in 1990,1 which recommended that general practitioners would be set prescribing budgets (albeit indicative ones) and that health authorities should appoint medical advisors, I realised that an exciting pharmaceutical opportunity was presenting itself. Within a short time, health authorities appointed pharmaceutical advisers under section eight of the Working Paper, to complement the work of the medical advisers. At that time, my background was in community pharmacy, hospital pharmacy and, latterly, general management in acute hospital care, and I had already established good links with some general practitioners (GPs) and with the family health services authority (FHSA). The FHSA was then the body responsible for the provision of general practice medical, pharmaceutical, dental and optical services. I was soon approached to assist in setting the first budgets - a daunting task, which quickly led to a part-time appointment with the FHSA that mainly involved monitoring the cost of prescribing. Across the country this was when pharmacists began working within the primary care environment outside their traditional dispensing role.

Peter Matthews: PCG pharmacists have a unique opportunity

Looking at the position today, with the burgeoning number of primary care groups (PCGs) all wanting their own prescribing advice, the opportunities for pharmacists to work in primary care are greater than ever. As in those early days, many of the PCG boards are mainly concerned with the containment of prescribing costs, if not actual cost reduction measures, and it will fall to the prescribing advisers to assist in this programme, while maintaining appropriate levels of prescribing quality. It will not be an easy task and the pharmacist will actively have to support the implementation of evidence-based prescribing, which may mean increased expenditure in some therapeutic areas. This will demand excellent research and presentation skills if PCG boards are to be convinced.
PCG boards will see the pharmacist as an independent source of advice and it will be for them to bridge the gap between the "lay members" of the board and the GPs, while maintaining the confidence of all.
Devising strategies to free up resources by reducing waste and ensuring that GPs prescribe the most economical drugs within a particular class will be important areas of work.

Improving patient care

The primary care pharmacist has an important place in the implementation of clinical governance within PCGs. Quality markers in prescribing will feature in all clinical governance monitoring, as will clinical audit.
The primary care pharmacist, operating at practice level, has the capacity to influence prescribing patterns to ensure that these quality markers are met. Primary care pharmacists with appropriate information technology skills will be able to assist practices in "painless" clinical audits using prescribing and clinical data extracted from practice computers. It is vitally important that the primary care pharmacist becomes involved at practice level. It will be a disaster if they become solely PACT analysers and newsletter editors. They have a unique opportunity to integrate into the delivery of clinical health care beyond the constraints of the dispensing pharmacy.
Within the GP practice, their involvement in therapeutic review "clinics" will have a tremendous impact on the quality of prescribing and patient-focused outcomes. The pharmacist's ability to use their traditional skills of communication with patients, and negotiating skills in general, will enable them to operate clinics with clearly focused objectives, such as stopping unnecessary proton pump inhibitors or, where appropriate, having maintenance doses prescribed instead. This is a particularly difficult task for GPs in a busy surgery and having someone available with the appropriate change management skills will be a boon to GP, patient and PCG board alike. For example, offering patient training and counselling in the appropriate use of inhalers will improve patient self-management in asthma and chronic obstructive pulmonary disease, with resulting cost savings and better patient outcomes. Domiciliary visiting to help house-bound patients manage their medication will become a standard facility within the PCG, with one or two specially trained pharmacists taking on this role, while spending most of their time in community pharmacy activities.

Primary care trusts

As the PCGs join together to form primary care trusts (PCTs), there will be a need for pharmacists with both clinical ability and a range of management skills to work at board level. It is quite possible that, within a short time, PCTs may have the freedom to negotiate their own drug contracts as happens in hospital now. Issues around formulary control, the use of new drugs, the relationship with hospital prescribing and the responsibility for the allocation and monitoring of a prescribing budget some 10 times larger than that of a typical hospital, will require the appointment of pharmacists with a considerable portfolio of skills and advanced training.
This training will not appear by magic and the Department of Health, the National Prescribing Centre and the Pharmaceutical Advisers Group should be planning now how to deliver this training, which is clearly beyond the limited remit of prescribing science. There appears to be no provision for training pharmacists working at health authority or PCG level in anything other than prescribing.
Looking even further into the future, I think that it is inevitable that community pharmacy service contracts will move to the PCT. It seems unlikely that, having divested health authorities of the bulk of their responsibilities for contracting with secondary care and the administration of primary care general practitioner and nursing services, future governments will deem it appropriate for community pharmacy services to remain outside the general model.
This transition will enable long overdue improvements to the contracting system, which will allow community pharmacists to play their part in prescribing as envisaged in the Crown report.² It will also enable community pharmacists/primary care pharmacists to take an active role in medication management, working in close co-operation with the local surgery and primary health care team, following locally agreed protocols but delivering these services using their pharmacy as the focal point. It will be in the interest of the PCT to reward the pharmacist for playing an active part in preventing unnecessary prescribing by GPs or by dealing with inappropriate patient demand.
At this point, the functions of the present primary care pharmacists and community pharmacists will have fused to produce a practitioner well able to take the profession of pharmacy forward into the new millennium.

Mr Matthews is a pharmaceutical adviser at Sandwell health authority

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