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Referral scheme in 30 pharmacies is alternative to GP pharmacists

Up to 8,000 fixed-time appointments are available at 30 pharmacies until September
Up to 8,000 fixed-time appointments are available at 30 pharmacies until September

Thirty pharmacies in South Tyneside have gone live with a pilot scheme which refers patients directly from GP practices.

Under the GP2Pharmacy pilot – which launched last month and will run until September – patients are triaged by their GP practice and offered one of 8,000 fixed-time appointments – including some weekend slots – with a pharmacist at one of 30 participating pharmacies.

The service runs alongside South Tyneside clinical commissioning group’s (CCG) “think pharmacy first” minor ailments scheme and means participating pharmacies can supply medicines for certain conditions, under a patient group direction (PGD), the CCG explained.

GP2Pharmacy programme lead Karen Large told C+D the scheme is the “perfect solution”, as “there wasn’t enough money to put a pharmacist full-time…into all of the GP practices in South Tyneside, and it wouldn’t be practical to do that”.

The service is “really utilising [the pharmacists’] existing skills”, as well as building on them, Ms Large said. Pharmacists involved have already undergone training under two PGDs – for impetigo and urinary tract infections, she explained.

Expanding on the scheme, the Pharmaceutical Services Negotiating Committee said it “also supports other planned patient appointments on a proactive basis, such as regular check-ups…long-term condition management (such as blood pressure), and semi-centralised, disease-specific clinics to assist with polypharmacy and compliance”.

“It’s not rocket science”

Louise Lydon, a contractor in Jarrow, South Tyneside – and part of the team that developed the scheme – told C+D it is a “natural progression” for the area, as patients have “been able to come in [to a pharmacy] and access the minor ailments scheme for about 10 years”.

Around 50 consultations were taking place per week when the pilot started last month, so “it’s probably more than that now”, Ms Lydon said last week (February 5).

Ms Large said the pharmacists involved seem “pleased”. “I think it’s something that a lot of people would have liked to have done for a long time.

“It’s not rocket science, it’s just making the process work for them, so the pharmacies that are up and running are quite happy for it,” she added.

Patients are also pleased, as Ms Lydon’s pharmacy is on a “very busy council estate, and we’re the only health professional on the estate”, she explained.

“The patients love the scheme, because they don’t have to drive or take [their] children to the GP surgery, which…isn’t closely located to our pharmacy.”

Hopes for the service

There are “about another dozen PGDs in the pipeline”, Ms Lydon said, and pharmacists will be undergoing training in March to conduct clinical examinations of the throat and the ear, so “we are really developing the scheme”.

Ms Large added that they should have a better idea of how the service is performing after two or three months.

But “it already feels like it’s going to be a success [and] there’s nothing we’re concerned about”, she said.

Ms Large is already planning to “approach the CCG before the end of the contract” to discuss extending the scheme. “It will be a real shame for people used to having that service if it stops.”

18 Comments
Question: 
Would your pharmacy like to be involved in a similar scheme?

Leon The Apothecary, Student

So as I understand it the scheme is basically minor ailments, with the addition of the GP to pass on the mundane queries to a Pharmacist? I'd like to know more information about how patients are triaged and at what point and by whom? Depending on the answer, this could be seen as postitive or negative.

My personal opinion is that Karen Large hasn't full realised how much cost saving can be achieved by having an prescription expert in surgery to minimise workloads, optimise cycles, and fully impliment Repeat Dispensing - a service that has been woefully underutilised and in my experience not well understood due to a lack of training for the individuals that encounter it, such as clericial staff who might not have the correct level of knowledge to realise eRD.

 As for Pharmacists in community pharmacy conducting physical exams, is the pharmacy a suitable location? I would argue an exam room is fundementally different from a consultation room, and the two are not compatable if one is aiming to achieve excellent quality healthcare.

 

Brian AUSTEN, Administration & Support

The funding for GP Pharmacists is tapered, the proportion of funding for the pharmacist paid for by GPs increases year on year until it becomes 100%. This referral service as far as I am aware is cheap funding compared to GP scheme funded by NHS England/CCGs. If the Pharmacy scheme is effective the funding and mechanisms/contracts for it need to be reviewed to reflect Community Pharmacy value and input.

N O, Pharmaceutical Adviser

In my opinion the GP (Clinical) Pharmacist is an equivalent of having an ACT in community Pharmacy. Both involve doing the dirty jobs for lesser pay. But, while the ACT is paid by individual contractor the GP Pharmacist is paid from the NHS budget (thanks to Mr. Cheap Pharmacist) So, for comparison, The C Pharmacist does nothing more than a clerical job but has the tag of Clinical (without any apparent greater clinical skills than their community couterparts) that would give greater access to some patient files than an ordinary desk staff, just as the ACT (by virtue of having done a course) has upperhand over a PharmaTech/ Dispenser.

But then, I would still prefer an ACT over the C P, since the ACT actually does take the better load of checking tonsof baskets while the CP becomes just another pen pusher.

Ronald Trump, Pharmaceutical Adviser

You sound like a bitter pharmacist near the end of his career who lost a ton of money due to the funding cuts and refuses to embrace change. Or someone who is trapped in a job he hates. Lets have some positivity for the evolution of pharmacy N O!

Richard Binns, Primary care pharmacist

I think the only purpose of this type of comment is for someone to attempt to prop up their own sense of self worth by belittling others.

I hope any GP pharmacists reading this are secure enough in themselves and their role to take this type of thing with a pinch of salt as its completely unecessary.

I do wish we could abandon this triabalism within the profession and employ our energies into actually achieving something for a change.

Interleukin -2, Community pharmacist

His comments methinks some of us find disturbing precisely because they have an omnious ring of truth lurking somewhere within...Oh dear has he touched on something there ? Am afraid he is right. Playing pretend doctor is the last thing any self respecting pharmacist should do now. Why does any pharmacists role need to evolve !!!!!?? I never heard of pilots' role or joiners' or nurses' role or GP roles evolving ! Why do they always pick on pharmacists !?

Richard Binns, Primary care pharmacist

The entire health service is constantly evolving, particularly GP roles (have a look at the new contract if you need confirmation of this), look at the increasing use of specialist nurse practitioners and ANPs,  the health needs of the population are signifcantly evolving, more people are living longer with multi-morbidities and frailty. treatments have switched focus over the years i.e. primary prevention. Thats why traditional healthcare roles have to adapt, to meet demands placed on the system.

please try to abandon the victim complex and accept change is part of professional life like everyone else, because the other option is doing nothing and  becoming obsolete. look how the manufacturing industry has changed with the automation of previously manual roles. 

N O, Pharmaceutical Adviser

Could you please clarify what exactly is the role/ duties of a Pharmacists in GP practice and with reference to any community Pharmacist who cannot do the same in a community setting. I would apprecite more of honest and actual role you prsactice than the glorified version from the Cheap Pharmacist. Thanks in Advance.

Richard Binns, Primary care pharmacist

Varies greatly depending on needs of practice and population, I think an example worth looking at would be 'polypharmacy' medication reviews, I know I have seen comments on here questioning why this is different to MURs already performed in community pharmacy. But I think they are some improtant distinctions regarding the services.

The current community pharmacy medication review is what is defined as a 'level 1' medication review, where by you are face to face with the patient and the only medical records you have to refer to are the pharmacies PMR system/patient repeat slip. So it is essentially a check of compliance and tolerance.

The polypharmacy reviews which there is a drive for pharmacits to complete as opposed to GPs, is what is categorised as a 'level 3' medication review, which incoproprates a face-to-face clinical review with full access to medical notes, the rationale for this type of review is that as the population is aging, they tend to accumulate medicines on repeat, hence increasing the drugs burden the patient is subject to. The issues  that concern us are the increased risks of side-effects with multiple morbidities and multiple meds as people get older, the patients tolerance to the meds changes with age (i.e. renal function deterioates), the treatment goals may change or no-longer be valid so the treatment is either no-longer indicated or no longer evidence based (i.e. antiplatlets for primary prevention). As the patient ages (and their drugs list likely increases) they become more frail, so minor incidents can lead to major and irreversible changes to their quality of life/ life expectancy (i.e. a fall or hospitalisation).

So the purpose of the polypharmcy reviews is to ultimately 'de-prescribe' with a view to improving the patients quality of life and avoid adverse incidents which may impact on the patients overall frailty (i.e. falls prevention).

The general advice when conducting this type of review is to determine what could be defined as 'essential' drugs - so medications which provide a essential replacement function (i.e. insulin) or medications which prevent a rapid deterioation of symptoms (i.e. epilepsy meds, parkinons meds).

The treatment goals for these meds should be reviewed in the context of the patient (i.e. bp, and hba1c), if the treatment goals are too agressive in the context of the patient and their frailty then they are likely to cause more harm than benefit.

Once the essential meds have been identified, then the othermeds can be reviewed with the patient discussing whether they are still required, using accumulative toxicity tools (such Ach burden) to calculate risk of events such as falls and impairment of cognitive function.

alongside of this the ongoing monitoring of the medications/disease state should be reviewed within this process (u&es,bp, hba1c, ecg etc), and measures should be put in place to prompt these to be checked by the surgery team when clinically appropriate.

Sorry for this long-winded example, and please dont take what I am saying as community pharmacists are not able to do this work  (although  Iwould stress that to conduct this type of review safetly GP/Hospital pharmacists should have some post-grad edication). The problem is that at the moment working in a community pharmacy you are not directley part of the care team with full access to the patient records and the ability to book follow up appointments/blood tests etc. So you could perform a brilliant review in that setting buts its not practical to actually facilitate any changes to the patients meds.

I think you need a close working relationship with the rest of the care team to undertake this level of review, as the risks of deprescribing can sometimes be greater than the risk of intitating a drug. For example you see a patient who is frail, has AF and is on a anticoagulant, you assess them using the appropriate tools as being too high risk of a bleed and decide with the patient the safest course of action is to stop the drug, the patient immediately has a stroke and the family decided to take legal action against you, is this a situation you would like to face working in a busy community multiple?

Im not trying to get into a game of one-upmanship with communtiy pharmacy, Im just trying to answer your question with an example.

I used to be a community pharmacist, I just think the current set up and contract limits the type of role that can be succesfully developed. Community pharmacy contractors get paid by 'volume', GPs get paid by patient outcomes/indicators, until there is a shift to reimburemnet for patient outcomes in community then the contractors will not support the development of these services

Interleukin -2, Community pharmacist

How you managed to delude yourself into thinking community pharmacists cannot do basic interventions just because its termed "level 1-3" is the very thing that shocks me the most about pharmacy. What exactly do you mean by polypharmacy ???? My biggest worry is that you actually believe this stuff. You mean like me politely asking the GP to change a statin and subsequently stop quinine prescribed for leg cramps cos statins the cause of cramp initially?? Such elementary stuff? Seriously!!! Community pharmacists across the UK do this stuff and more everyday many times per shift. Its called being a pharmacist ! Thats what we do !

For your information some of us actually set out to be pharmacists serving the community and thrive on it, we didnt try to get into medical school and failed and hence ended up with a debilitating inferiority complex

Richard Binns, Primary care pharmacist

would you stop the statin based on leg-cramps without checking creatine kinase for evidence of muscle damage from Rhabdomylosis (which is the potentially quite dangerous side effect from statins). Most of the population suffer from leg cramps without assuming its a side-effect of statins, I  think the incidence of this type of side-effect in statins is around 1 in 100,000, so I wouldnt jump to conclusions before advising patients.

What I would consider when reviewing a statin in an elderly patient is the 'Q Risk', NNH and NNT, to determine what actual benefit we can expect from the intervention in realtion to the patients percieved life expectancy, which Im sure you are doing whilst performing your clinical role? 

Also with regards to the quinine, Id be far more concerned with the risks of QT-prolongation, relative toxicity and complete lack of evidence in its use;

https://www.gov.uk/drug-safety-update/quinine-not-to-be-used-routinely-for-nocturnal-leg-cramps

Like you said 'elementary' stuff!

Richard Binns, Primary care pharmacist

 

If you dont understand what polypharmacy is then look it up. It has been discussed in other articles on here and may well have a bearing on your future role.

 I am genuinley sorry I couldnt get my point across any clearer in my quite lengthy post, heres a couple of  references that support what I was trying to illustrate, I hope you can see from them, what I am describing is all evidence based practice, rather than my personal 'delusions'.

https://www.kingsfund.org.uk/publications/polypharmacy-and-medicines-optimisation

https://www.therapeutics.scot.nhs.uk/wp-content/uploads/2018/09/Polypharmacy-Guidance-2018.pdf

Richard Binns, Primary care pharmacist

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Interleukin -2, Community pharmacist

We can evolve....yes by all means but has anyone stopped to consider evolving within the dispensary? Like being better community pharmacists working in pharmacies within the community and serving the community? I like what I do just need to be paid better, appreciated better and protected from non pharmacists supermarket and big chain managers asking me how many "MRU" s i ve completed today? Surely thats not too much to ask ? I just dont want to be in a GP surgery .I want to be a pharmacist .

Leon The Apothecary, Student

The way Dispensaries are evolving these days, the need for a Pharmacist on-site in practical terms is becoming less required and continuing to be less so with projects like Remote Supervision, Accuracy Checking Techs and Dispensers, Barcode Verification via FMD, and Standardised Dosage Codes and Centralised Dispensing Models.

Richard Binns, Primary care pharmacist

I don't see anyone asking you to work in a gp surgery? that's a personal choice that I and others have made and I can assure you is not a judgment of anyone else working in a different sector.

Richard Binns, Primary care pharmacist

You can evolve in a dispensary without publically
criticising people who have chosen to work in a gp surgery. Each to their own and good luck

Richard Binns, Primary care pharmacist

Well that was incredibly insightful thank you for feeling the need to share.

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