Pharmacists prescribing better care

As the NHS celebrates 70 years of providing health services in primary care, NHS England’s Chief Pharmaceutical Officer details a visit he made to a GP practice in Westbourne, Bournemouth:

According to a report in the  British Journal of General Practice (BJGP) published in February, a GP practice serving around 30,000 patients can expect to issue half a million prescriptions a year.

They will have 1,000 patients on more than eight medicines, there is a potential prescription error rate of 5%, and they might reasonably expect around 300 medicines-related, non-elective hospital admissions.

With that in mind, a visit to Westbourne Medical Centre (@WMC_GP) brought home to me the changes that are happening in primary care through the initiatives of health professionals in surgeries, pharmacies, and other practices.

The word I heard most frequently from our hosts was ‘team’ and during the visit I spent time with a patient, two GPs, a community pharmacist, a pharmacy technician, a nurse practitioner, a practice business manager, a clinical governance and quality manager and a receptionist, as well as Steve Williams the clinical pharmacist in the practice. They are all part of a high performing, integrated, multidisciplinary team dealing with complexity in primary care.

With every person I met, conversation centred on how clinical pharmacy practice is helping to contribute to team capability within the GP surgery context or as our hosts described it “the unit delivering care”.

For the patient we met, Mrs G, who is taking multiple medicines, capability had been demonstrated by the medicines review she had received. She is feeling better and more confident as a result of changes to her medicines and has improved quality of life – so much so her friends are asking, when might they have access to a clinical pharmacist in their GP practice? The letter she had received inviting her for a clinical medication review had been a welcome initiative; she now understands her medicines better.

For Dr Lawrence Brad, partner and practice prescribing lead, it was a learning opportunity, the ability to go to the next level of prescribing expertise and a door into specialist knowledge for the practice and local health system.

For nurse practitioner Janine Foy, it was the benefit of the sharing professional knowledge both ways; a productive working relationship and key point of contact for medicines queries.

It was rewarding to hear people describe the contribution which Steve has made to the team. The developments are impressive.

In a BJGP article , Steve and Lawrence, along with Jamie Hayes, wrote: “We believe metrics to assess all changes in general practice need to be relevant, objective, and easy to collect… We agreed an average time needed to perform such activities, which otherwise would have been done by a GP, and have estimated that one post saves GPs 80 hours a month (excluding indirect patient activities). Identifying outcome measures has been much more challenging. In the absence of any other reliably sensitive and specific quality measures, we are using the new national medicines optimisation polypharmacy comparators.”

Eighty hours a month is equivalent to two working weeks a month across the practice.

To list the main achievements, Steve:

  • Has introduced a new repeat medication policy, ensuring more patients have a medicines review, and reducing prescription queries.
  • Provides daily telephone consultations for patients with medicines related questions.
  • Runs medication review clinics for people on multiple medicines which include Quality and Outcomes Framework reviews for patients with long term conditions.
  • Provides a care homes prescription management service for 300 residents.
  • Helps the practice fully achieve its annual medicines optimisation incentive payments, including improving prescribing of antibiotics and blood thinning agents.

In the same article, the authors wrote: “Subtlety and complexity of medicines and the increasing amount of NICE-endorsed and hospital specialist ‘silo prescribing’ means medication review by medicines experts in primary care is now essential. However, this type of work is currently difficult to achieve in general practice due to a lack of dedicated time and appropriate specialist skills. We believe such complex medication reviews should be the focus of practice-based clinical pharmacists.”

I agree and with NHS England’s recruitment of 2,000 clinical pharmacist posts heading for over halfway – 1,250 WTEs by this summer, across 2,900 GP surgeries – this ambition is within sight.

With the growing evidence that some patients are on some medicines for too long, or on medicines which are no longer suitable, practice-based clinical pharmacists will help to deliver better outcomes for patients, including, stopping some medicines.

Along with the 240 new clinical pharmacy professionals being recruited to work in care homes, it’s clear that during its 70th year the NHS increasingly will be able to offer those who need it, like Mrs G’s friends who are on multiple medicines, a clinical medication review.

Dr Keith Ridge

Dr Keith Ridge is Chief Pharmaceutical Officer at NHS England where he is head of profession for the pharmacy professions and the principal advisor on pharmacy and medicines use.

His role supports the Department of Health, broader Government and Health Education England.

Keith is the Senior Responsible Officer for reducing inappropriate prescribing of antimicrobial in the UK AMR Strategy, and leads on issues such as medicines optimisation, digital medicines, pharmacy educational reform and transforming pharmacy practice in line with the NHS’s Five Year Forward View.

He is a visiting professor at the Imperial College Medical School.