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PCN pharmacist: The impact of reducing face-to-face patient care

“We had three categories of GP surgery – hot, cold and frozen”

Working as a PCN pharmacist during the COVID-19 pandemic required my primary care network (PCN) to implement remote care for patients, says Danny Bartlett

When lockdown began on March 23, my primary care network (PCN) in West Sussex decided, on government advice, to partially close all three of our GP practices in a staged approach. We had three categories of site – hot, cold and frozen.

The “hot” surgery was specifically and exclusively for patients with COVID-19 symptoms. Clinicians working at the hot sites had to wear full personal protective equipment (PPE) and the appointments were triaged based on severity. The “cold” site was for patients that had acute problems but no COVID-19 symptoms. We closed the third, biggest practice – the “frozen” site – where I, some of the GPs and the majority of the clinical staff went.

In terms of appointments with patients, my clinics that had previously been face-to-face medication reviews were replaced by telephone appointments. This was the same for GPs working at the frozen site. It prevented some of the patient-clinician relationships being established as well, but actually improved the speed and effectiveness of the questioning and the turnaround of appointments.

The main issue that I have noticed in practice is that much of my safety monitoring and PCN-orientated clinical projects have taken a back seat. The main barrier was that the government's shielding advice, particularly for patients on immunosuppressants, prevented them from being able to leave their houses for blood monitoring.

The advice meant that the majority of the patients on drugs such as anticoagulants, disease-modifying anti-rheumatic (DMARD) drugs and even more common drugs such as angiotensin-converting enzyme (ACE) inhibitors could not be monitored on their renal function and blood count unless instructed otherwise.

The patients on DMARDs were stratified in terms of risk. Discussions with consultants and their recent renal functions were also taken into account to extend the blood test intervals needed. This allowed me to continue to oversee monitoring across my PCN and to make clinical decisions on an individual basis on whether to refer a patient to their consultants.

A key issue we have faced in the current crisis has been unnecessary and unindicated medication ordering, and the pressure it put on pharmacy stock levels and medicine teams in my GP practices.

The most significant example was a spike in patients ordering inhalers. This led to a 30% increase in the inhalers we issued over two weeks. Patients with seasonal asthma who were not necessarily symptomatic were ordering their inhalers to have a supply of them should they develop symptoms. Patients who had not ordered their inhalers in over three years were also putting requests in for them.

This had a knock-on effect on the stock of inhaler brands such as Clenil and Soprobec and led to an increase in triaged query phone calls for both me and my team. When this was queried with the respective patients, it was apparent that they did not need inhalers as they were asymptomatic and had been for an extended period.

Overall, the virus has impacted my practice in reducing the face-to-face clinic time I have and altering the outlook on monitoring requirements associated with high-risk medications. Although it has perhaps increased the workload in most of our day-to-day processes, I feel my PCN has coped and adapted very well in this strange time.

Danny Bartlett is a senior clinical pharmacist for the Coastal & South Downs Care Partnership PCN.

16 Comments

Andrew Boyle, Community pharmacist

Like the 'frozen' description. 

Unfortunetely describes the all too familiar 'relationship' of many GP Practices with Community Pharmacy.

After a 'freeze' on direct pharmacy ordering of repeats on behalf of patients before COVID-19 we were 'allowed' to provide this service. Now this is being gradually rescinded as-presumably-we can't be trusted.

 

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

I wonder if one of the GPs dressed up as Elsa....?

Freelance Chemist, Pre-reg Pharmacist

Not a very professional picture, please change it ASAP. 

Alan Glauch , Non Pharmacist Branch Manager

 

 

 

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

The impact of reducing face to face patient care in a PCN setting has been to INCREASE face to face patient care and therefore risk in a Community Pharmacy setting. Once again, we are being used as cannon fodder to protect those considered by the NHS to be superior to us, i.e. everyone else.

Incidentally, what the hell is Soprobec?? I've been doing this crappy job for 30 years and I've never heard of it!

C A, Community pharmacist

A Clenil by any other name would smell so sweet

Danny Bartlett,

I think the NHS's aims were to increase the quantity dispensed at a time to reduce face to face contact in community pharmacies. There was never going to be a happy medium between no contact and maintaining patient care and I agree with you it was doomed to fail at the first hurdle and our pharmacy within our practice noticed an increase in footfall particularly in the first stages of lockdown.

Soprabec is beclometasone and has a similar particle size to clenil so was the next best alternative to clenil when they went out of stock. Qvar is obviously more potentdue to the extra fine particle size so would not have been such an easy switch. Pharmacies in our locality were advised by us to go for that as an alternative to reduce workload on them on back a forth dose change. Hope that helps

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

Is it one of those odd branded generics? Worth knowing about anyway.  Sorry, I sounded a bit grumpy before - it's early!

It is noticeable though that footfall has gone down a lot. At the start of lockdown there were massive queues of pretty hacked off people waiting outside my local surgery pharmacy and the place was utter chaos, but the last three times I've been down there hasn't been a soul waiting. I still think community pharmacy is seen as the bottom rung of the ladder in all things though.

"Unnecessary and unindicated medication ordering".  Interesting?!  Our local surgery literally churned out two or three months worth of every possible repeat item from very early on.  No indication of which patients needed meds acutely and which were being prescribed "to cover the pandemic".  Caused absolute chaos, stock shortages and has led to lots of our patients now having three months worth of repeat meds sitting at home- some of which they will never use again.  They've been allowed to carry on ordering month on month and will obviously continue to do so until stopped.  It's also been a case of whoever shouts the loudest gets what they want-many of our younger, mobile and perfectly able patients demanded, and got, three months worth of meds while lots of our older, less confrontational patients continue to struggle to fulfil their basic needs.  Shocking!

Danny Bartlett,

 

Yes that sounds like the surgery were bowing down to the patients far too early and probably horribly impacted your stock levels and workload. I think the majority of the problem was patients being given so much so quickly by not only the surgeries but the pharmacies supplying. Stock control should be a measurable service espescially in a pandemic and the ownership is not soley on the prescribers. I think the 'panic state' early on had a knock on effect on both surgery medicines teams and pharmacies alike

 

 

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

Remember though, we are contractually obliged to dispense the full amount against a legitimate prescription. It isn't for the pharmacist to decide how much a patient should or shouldn't have. If we had to phone a GP every time they issued a triple script or issued too soon, we would never be off the phone, especially given the half hour lectures you have to endure first on the GP answering systems.

Ronald Trump, Pharmaceutical Adviser

How about using one's initiative during a pandemic and thinking what would be in your patients best interest?

It's called utilitarianism.

And you wonder why GPs and the public think 'chemists' are dodos.

I hope the new pharmacists coming through are able to think on their feet, be more pragmatic and take more responsibility and autonomy with their decisions.
 

How do you know that I didn't?  We spent the first four or five days looking through the daily 2 foot pile of scripts we had, trying to decide who we should prioritise.  Our current delivery patients,  patients who we know would become "vulnerable/ shielded" patients, etc. This was while we were dealing with maybe 30+ patients in the Pharmacy at one time, all day every day.  Several pharmacies had to call the police to resolve disputes between pharmacists (or staff) and patients who demanded that they be given everything on a rx.  They knew we had the scripts because the surgery staff had told them.  We were dealing with patients who were terrified, worried about being left lonely and isolated in their own homes.  Patients who the surgeries refused to see and directed to their Pharmacist instead.  It was absolute carnage. So many of our regular patients were distressed and needing help and we were the only professionals they could turn to.  It became quicker and easier to process every script just so that we knew we had it and could put our hands on it, amongst the literally hundreds we had.  We turned away maybe 100 patients a day at the beginning while we tried to work out the best way to deal with the workload.  Maybe you could have volunteered to help out in a pharmacy during the lockdown?  I had a GPHC inspector walk in one day, roll her sleeves up and get stuck in because she knew the pressure we were under. At least we kept our doors open and looked after patients when nobody else would. 

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

If the law says you can't Mr Trump, unlike what your namesake thinks, YOU CAN'T. As far as I'm concerned, what is in a patients best interests is to do what their GP wants. He is, after all, the one with the duty of care. We do not hold that overall responsibility because the patient has the freedom to choose which pharmacy they go to, but their GP practice is limited by geography. I'm not going to 'use my initiative' to illegally limit supplies of medication to a patient who may have a perfectly legitimate reason for requesting multiple supplies.

No wonder pharmacists think spurious 'pharmaceutical advisers' are a waste of air when they come out with the levels of bile and lack of support for an already beleaguered profession as you do. Were you scared by a man in a white coat when you were little and are now determined to undermine the whole lot of us? Frankly, there is not a grain of 'advice' I would be prepared to take from you.

Alan Glauch , Non Pharmacist Branch Manager

I am sure that most Pharmacists would use their initiative and consider what would be in their patient's best interest.However as Community Pharmacists, perhaps unlike "Pharmaceutical Advisers"are soo accessible  to patients presenting such prescriptions they adopt the most practical solution and if clinically safe, dispense the medication that the prescriber intended to avoid the arguments. I may be totally mistaken but I suspect that the above Adviser has had little experience of Community Pharmacy.if that is the case I am sure that a local Pharmacy in their area would be more than willing to host a visit.

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

Not so sure about that! I wouldn't mind being a fly on the wall though. For me, having done this job for far too long pragmatism trumps (no pun intended!) utilitarianism every time!

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