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RCGP chair warns pharmacists to stop duplicating doctors' work

Practice Pharmacist interventions such as MURs are causing unnecessary work for GPs, RCGP chair Clare Gerada told the C+D Summit last week. She urged pharmacy to instead focus on medicines management and comorbidities

Pharmacists should stop duplicating GPs' work and instead help the medical profession to tackle complex conditions, Royal College of General Practitioners (RCGP) chair Clare Gerada warned the C+D Summit last week (April 11).

Dr Gerada said that it made "a lot of sense" for GPs and pharmacists to work more closely, but both professions had to avoid pretending they were exactly the same because pharmacist interventions were causing more work for GPs.

NHS commentator Roy Lilley told delegates that GPs would struggle to manage their workload without pharmacists in the new healthcare environment, as primary care doctors took on services previously managed in secondary care.

"There isn't a single [pharmacist] intervention I can think of except batch prescriptions that has reduced GPs' workload" Clare Gerada, RCGP

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But Dr Gerada said that initiatives such as MURs had increased GPs' workload at a time when surgeries were "heaving under the pressure", because doctors needed to "review the review" and bring in the patient.

Pharmacists needed to understand that telling patients to see their GP at the moment "may well be the straw that breaks the camel's back", she said.

"There isn't a single [pharmacist] intervention I can think of except batch prescriptions that has reduced GPs' workload," Dr Gerada told C+D. "So I think it's important from a pharmacist's point of view that they take work away from the GP and don't just duplicate [it], which usually involves us having to do more work anyway."

Dr Gerada named medicines management and complex comorbidities as areas where pharmacists could play a stronger role.

Mr Lilley told delegates that pharmacy could manage the bulk of long-term conditions. "Once the GP has diagnosed... the patient could then be looked after at the pharmacy," he argued.

But GPs could actually prove a "stumbling block" in pharmacists assuming this wider role, Mr Lilley warned. "Unfortunately GPs are the ones who are commissioning and why should they see money walking out of the door?" he asked.

Workload pressure was the only motivation for GPs to give up services, Mr Lilley stressed. "If you're going to drag stuff out of hospitals and stick it in surgeries and look after everyone with a long-term condition, you're going to need [more capacity], that's for sure," he said.

"I can't understand why GPs want to do more and more work when it's clear they're not going to get more and more remuneration," Mr Lilley added. "At some point in time, they will twig that if they commission some of the things they struggle to deliver to places like community pharmacy, they will make their businesses more profitable and won't sit there whinging about falling income and [increasing] workloads."

What do you make of Dr Gerada's comments?

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Rob Morris, Community pharmacist

We know Dr Gerada has no respect for pharmacists. Where is this antipathy coming from because the vast majority of pharmacists works as hard, or harder, than GPs? Research shows we see more of a GP's patients in a year than they do and we counsel and advise them freely - particularly out of hours when GPs are nowhere to be seen. I believe there is mutual respect in most GP:pharmacist working relationships so Dr Gerada is not representative which is worrying for some one in her position.

Amal England, Public Relations

Clare's anti-pharmacy rhetoric is plain, a clear reflection of her intelligence and inability to grasp the mountain facing the NHS and how to deal with it. True, let it be a warning to all of you pharmacists- standup and fight for profession or you will be nothing. Where are the so called pharmacy leaders/champions spearheading a scathing attack on this hypocritical Clare? Is there no pharmacist working for the C+D publication that could put forward an opinion that reflects what pharmacists feel about the ill informed view of Clare's and putting forward a counter argument to highlight the many additional roles that can be devolved from GPs to pharmacists, saving hundreds of millions of pounds and printing that opinion in a broadsheet? Pharmacy as a profession has become a father-son relationship in which the father just let's the son go downhill, losing soul, meaning and purpose.

Mahesh shah, Pharmacist Director

GP workload is increased not because of Pharmacists but because of government policy (no demand management) and the medical profession's failure to pro-actively lobby to move the management of minor ailments to pharmacy. I am not sure of the latest statistics but almost 39% of GP consultations were due to minor, self-limiting illnesses that could be dealt with by Pharmacists. The data from walk-in clinics was even more staggering - almost 90% of cases were for conditions that are dealt with daily by pharmacists. The cost to the taxpayer for a walk-in centre consultation is about £35. So Dr Gerada, if you want to reduce the workload for GPs, engage with government to develop policies to relieve GPs the burden of dealing with minor ailments. No doubt some MURs will lead to a greater workload for GPs but have you measured the benefits from greater concordance? Mrs Smith's better understanding of her brown and blue inhalers may well result in better patient outcome, less GP visits and less hospitalisations.

Ian Strachan, Community pharmacist

Rather rich from Dr Gerada to speak of pharmacy duplicating the GPs work stream when surgeries are actively seeking to establish pharmacies through Internet provision of the regulations.Hardly the intention of this exemption, to duplicate the respected and valued tradition of pharmacies surely.

Paul Rolfe, Community pharmacist

Paul Rolfe, cyclist first pharmacist second
If the GP's are not happy it is best dealt with at a local level feeding back to pharmacists who are making more work and communicate to them what they would like or expect from MURs. This I have tried and tested and am grateful to the GPs since it helps me improve my practice and cater more to the local needs.

Mark Green, Community pharmacist

Since when was the purpose of Pharmacists interventions to reduce GP workload? The interventions that I make have one aim - to improve patient care!!! If a consequence of this is percieved "increased workload" in the short term I am confident that such interventions reduce unnecessary GP consultations and have a downward effect on future workload.

Samson Famojuro, Locum pharmacist

Sam,Community Pharmacist.
I found Dr.Gerada's comments quite interesting.A throw back to the times
when Dr's felt that a Pharnacist's place was dealing with and sorting out 'batch
Prescriptions'.So was I increasing GP workload when an Mur I conducted
revealed that the patient had actually unilaterally stopped taking her Pravastatin for about a year although she was still being prescribed this medicine by her GP,and was still ordering it on repeat slips?Was I increasing GP workload when a health professional I conducted an Mur on,confided to never taking her 75mg Aspirin,since according to her 'she doesn't have any pain or inflammation '?She certainly didn't think so when,before her exit she said' know you just might have saved my life' Maybe GP workload (and stretched NHS resources)would have been best served if she suffered a stroke and ended in secondary care,and the primary care .Was I adding to the GP burden when ,while conducting an Mur,I performed a routine Inhaler technique check only to discover that a patient whose Asthma had gotten progressively worse recently(she was now on Loratadine,and a spacer device
she found totally unnecessary)was simply using a fundamentally wrong inhaler technique.Need I go on?Until Drs accept that while they are not drug experts,and Pharmacists are not clinicians,patient outcome would only improve if Drs and Pharmacists work together in mutual respect and sing from the same page.

Yuri Wabuke, Community pharmacist

I have just clarified with a patient that taking Nurofen for her arthritis while on Citalopram could increase her risk of having a tummy bleed and should be discouraged. I have highlighted the role of paracetamol as recommended first line treatment taken regularly rather than PRN. I have clarified that she can take senna for the constipation arising from the prescribed codeine. I have set her mind at rest about pramipexole for her restless legs even though there are lots of references to Parkinson's Disease in the leaflet. How has this increased the GP workload?

A Medicines Use Review is exactly what it says in the title, a review of how a patient uses their medication. This often brings up surprising results that GPs may not be aware of for example intentional non-adherence (patients ordering medicines, but not taking them because they don't want the doctor to know!), and often don't result in a referral to a GP as issues can be discussed and resolved there and then with a qualified healthcare professional. It is about enhancing a patients knowledge of their medication(s) and their conditions so that the NHS is getting the biggest "bang for its buck", and is also a great platform for Healthy Living advice. I would agree with most of the other posts that the few referrals I make are about potentially more serious issues that a GP should be aware of. Maybe if Ms. Gerada spoke to the chap who I did an MUR on today who's OAB was not being treated adequately with tolteridone but was just putting up with it because "they didn't want to bother the doctor", she would see the value of this valuable service (to PATIENTS) that we offer. Everybody is busier, we need to work more collaboratively to empower patients to manage their health and conditions better.

Rajive Patel, Community pharmacist

The above comments, together with the reported article, demonstrate a huge disconnect between the two professions. When there is change in a market, there is uncertainty. This uncertainty can manifest itself into "Turf War".

This is possibly, more than anything, related to poor leadership and communication between both professions. Too many big ego's, more concerned about personal opinion, rather than forging a "working" relationship to harness the strengths of each profession to bring about a better overall experience for the patient, and hence leading to better patient outcomes.

I think Dr Gerada has a very valid point. Just look at how Boots launched the Diabetes screening scheme. They acted unilaterally, without consulting HCP stakeholders and handed results to the patients who all went in their droves to their local GP. Naturally, GP's were not prepared for the influx and quite rightly frustrated.

If leaders of both professions worked together to find a solution on collaborative work, and put the patient at the heart of their planning, whilst respecting scarce NHS resources, maybe then we would co-habit peacefully and successfully. We should not kid ourselves (never mind what these fantasy-seeking, jumped up pharmacy leaders think), we are not Clinical managers and Doctors are not Drug Experts! However, together are combined disciplines can help improve overall health outcomes.

Amal England, Public Relations

What you say is utter rubbish. There are no egos big enough in pharmacy to match the egos in the medical profession. What you fail to see or realise is the strangle hold doctors have on the NHS and its time you and all in the profession wake up and realise that doctors do not want to work with pharmacists and certainly not at the expense of NHS money. There is currently no leadership in pharmacy that a doctor will harken to. This Clare is an ill informed doctor with no insight into your 'turf', wake up smell the rot- the more work pharmacists duplicate the greater the chance of that work being eventually devolved entirely from the hands of the doctors and that means less money for the greedy doctors.

Alun Morgan, Community pharmacist

I agree with some of the points your making but not in the way your coming accross with them.

There is tension at the moment, granted, but where is all this tension coming from? When the GP governing bodies stop seeing pharmacy as a supply chain and someone to do the admin of synchronising prescriptions, and start seeing pharmacists as health care profesionals who act in the interests of improving patient safety and medicines optimisation; there will be more peacful cooperation!

I agree that pharmacists must always bear in mind that an intervention may cause more work for other HCPs, when considering referal and I am not accusing all GPs of behaving in this way, most I have dealt with dont. It seems that most of these views are expressed by the regulatory bodies. If a pharmacist intervention increases workload because a potentially dangerous interaction arises, then so be it, the end result is improved patient care.

Pillman Uk, Community pharmacist

I'm tired of hearing the "practice pharmacists" making sniping comments about the quality of MURs. What are you doing to improve the quality, do you give feedback? Do you try to engage with the pharmacists?

Also pharmacists interventions aren't about reducing GPs workloads, it's about the patient, and I'm sorry but I guess there are a lot of "appropriate" interventions that ARE increasing workload, but hey, its all about the patient.

Perhaps the GPs would like to divest themselves of some of these cumbersome issues (oh and the funding associated with them) and I'm sure pharmacy will be there to assist.

We could go on and on, batting this ball backward and forwards between the professions, getting nowhere.
Lets try and work together, making appropriate referrals, and GPs accepting that sometimes their patients will cause them further workloads.

Alun Morgan, Community pharmacist

I send few referral forms from my MURs to GPs, there is often no need, I tell patients to discuss on next routine appointment if it is not an urgent issue. The MURs i do send to the GP contain intervention I genuinely believe need attention - e.g. using aspirin alongside warfarin, without consultant supervision.

I would love to know if any GP would prefer us not to flag such issues and deal with a lawsuit when the patient gets harmed from such a things not ever being questioned.

As to the pharmacists who believe MURs are not useful - I would go as far to say that you cant be making much effort with them! Since the new MUR format came out, I have been discussing lifestyle with every patient (at very minimum do you smoke or drink at all) and where possible discussing diet and exercise. Far more interesting to get more involved with patients and i'm certain this sort of work is saving GP time!

Big Pharma, Superintendent

This article is fortified with fallacious reasoning.
para 1: duplicating gps work is a poor pretext and sets up for self defeating rhetoric. Had this been the case GPs would not be committing rudimentary prescribing and clinical errors.
para 2: the straw man fallacy. pharmacists do not pretend they are Drs, however, the converse is true, i.e. dispensing drs!
para 4: gps would not need to "review and review" if we were simply plagiarising pharmacists. we care. read post rachel clements
para 6: suppressed statistics read post by Harnek Chera
para 7: pharmacists do not discriminate between diseases. all are equal. all are given equal attention.
para 8: without patients clinical notes holistic care of patients is difficult and currently exists on the same level as unicorns, fire breathing dragons and fairies.

Gerry Diamond, Primary care pharmacist

Medicines review is part of the medicines optimisation cycle and the quality of some GP meds reviews are not so great to be honest. Perhaps GPs need to employ pharmacists in the practices and I don't see a big scramble by GPs to stop practice nurses managing respiratory, diabetes and cardiac risk assessment of patients. Dr Gerada needs to be clear what she does want to deal with coughs and colds, bad backs can all be dealt with by competent pharmacists.

What we really need is more community pharmacist prescribers to work in partnership with GPs to manage chronic conditions with registered patients to each pharmacy.

David Sharp, Community pharmacist

one more straw please ,my local gp has just told me my ccg has no interest in pharmacy services it is out to line the pockets of gps
most of my mur patients just want to know what they are taking and how to take it,a chat,a little time and care perhaps that takes the gps time as well ,
if all the gps did not have several jobs the haystack would feel lighter

Mary Louise Parkinson, Community pharmacist

Since when did pharmacists fill the vacancy nurses once historically held as the doctor's hand maiden? A pharmacist's role is more than helping the doctor out!

Chris Pillman, Community pharmacist

As most of my colleagues, I have conducted an astonishing amount of MURs now. The majority I conduct involves small changes to how a patient takes their medication (timing, after/before food/milk, etc) but since the changes last year I speak more indepth about lifestyle with the public - do you smoke? We have smoking advisors able to offer free aids in this pharmacy, let us book you an appointment. Raised cholesterol/diabetes/blood pressure? Let's talk diet!

I probably refer to the GP one in every 30 MURs if I am honest, but the referal is only when necessary and the patient or pharmacist can not do anything else.

A GP would only have any real knowledge of the review in the case of referral - which is quite rare from my view point. And if a referral has been made, then that patient has already slipped through the GP's net and been allowed to continue medicating without proper guidance, or there has been a drastic change since their last review requiring urgent attention.

And if we're talking money, I'm fairly sure I remember a report saying how great value for money MURs offered VS GP time. They were designed to save GP time (a few million hours a year) and reduce hospital admissions.

Maybe the real point is GPs don't know how to let go and allow other parts of the NHS take part of their workload.

Vanessa Collins, PCT pharmacist

As a Practice pharmacist I can count on one hand MUR's that have been truly useful to the patient or needed follow up by the GP !

Shahid Bashir, Locum pharmacist

In reply to Vanessa's message above, I think that may reflect the fact that the important issues have not been dealt with or maybe incorrectly referred. Would love to hear of the "useless" MURs you have been sent

Rachel Clements, Community pharmacist

Pharmacist's aren't in the business of reducing GPs workload. We are in the business of improving patient outcomes.

David Renfree, Non healthcare professional

Pharmacies get paid for MURs, they too do not want to lose income. You wouldn't ask BMW sell fewer cars because it's causing trouble for the Highways Agency, you'd speak to the Government.

Shahid Bashir, Locum pharmacist

Usually MURs result in no extra workload for GPs because the issues are usually dealt with by the pharmacist. In fact for these occasions where GP intervention or referral is not required we don't even have to send the MUR forms over, . The type of MURs dr gerada refers to are interventions and are defined as those situations where continuation of the drug in question or not intervening would cause a detrimental outcome eg myopathy with statins, dry cough with ACEI, neutropenia with carbimazole etc etc. so overall it would reduce GP workload and reduce cost to the NHS in terms of reduced hospital admissions and even possible reduced cost of drug where alternative is suggested.

Lance Roth, Manager

I know Dr Gerada, and if she says that our services have increased the GPs workload, she will have adequate data to back it up. But that is not the real issue. The issue is the fact that as the two biggest players in the medical field, leaders from both professions have fail hugely in serving the patient's interests. My question is this: Why were the RCGP not consulted when MURs as a service were being designed? Do the 'big boys' ever talk? SAD!

Harnek Chera, Community pharmacist

So, minor ailments schemes, pregnancy testing, smoking cessation etc. haven't reduced GP workload? Do GPs realise that Pharmacist workload has increased immensely in recent years whilst income has dropped dramatically? MURs may have increased some GP workload but patients seem to welcome the time they receive with Pharmacists during an MUR rather than see their GP and be told they can only discuss ONE issue at that appointment. MURs are a recorded and audited development of what Pharmacists have been doing for years for their patients. Caring!

Big Pharma, Superintendent

This article is fortified with fallacious reasoning.
para 1: duplicating gps work is a poor pretext and sets up for self defeating rhetoric. Had this been the case GPs would not be committing rudimentary prescribing and clinical errors.
para 2: the straw man fallacy. pharmacists do not pretend they are Drs, however, the converse is true, i.e. dispensing drs!
para 4: gps would not need to "review and review" if we were simply plagiarising pharmacists. we care. read post rachel clements
para 6: suppressed statistics read post by Harnek Chera
para 7: pharmacists do not discriminate between diseases. all are equal. all are given equal attention.
para 8: without patients clinical notes holistic care of patients is difficult and currently exists on the same level as unicorns, fire breathing dragons and fairies.

Harnek Chera, Community pharmacist


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