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'Gold in them hills' - why pharmacists are the future of general practice

Dr Dean Eggitt believes pharmacists offer the true nuggets of hope for general practice 

General practice is in a workforce crisis like we have never known. We have been promised 5,000 extra GPs by 2020 but the current progress toward this target casts a dark and foreboding shadow of doubt. Despite this workforce crisis, patients continue to seek professional healthcare advice in record numbers showing that demand is outstripping capacity in this NHS on the brink of catastrophe.

A cynic might suggest that the 5,000 GPs are never going to arrive, that this statement was just a useful soundbite to silence the cry for help from the emergency LMCs conference calling for the undated resignations of our workforce.

The reality is that GPs are expensive, both in temporal and fiscal terms. It takes 10 years to grow a GP from scratch, costing a debatable £498,489. On top of this, GPs are expensive, demanding six figure sums for full time work. With a £20-30 billion funding shortfall expected by 2020 you can start to understand why expanding the GP workforce might not appear to be an affordable solution. Admittedly, this viewpoint requires you to overlook the argument of ‘getting what you pay for’: if you’re stuck on that, then don’t bother reading on.

One solution is to use physician associates. Indeed, we have seen that physicians associates have been used successfully across the pond, and our own Royal Colleges here in the UK seem to be advocating that we also pan this river of workforce gold. The arguments for and against this have been rehearsed in detail elsewhere, so I won’t labour these points.

In my mind, we already have an abundant resource that doesn’t need mining or panning, but needs refining and polishing. A workforce that, having completed five years of undergraduate education, sit in plain sight, already working hard in the NHS, waiting to be realised. These professional colleagues and friends gained the ability to prescribe independently in 2006 and are already nationally regulated and independently accountable for their actions. Furthermore, they are required to be indemnified against such actions, understanding the risks of litigation as we do in general practice. ‘Who are these professionals, who might answer our calls?’, I hear you ask. ‘Pharmacists,’ is my reply. I believe this profession is an element in current abundant supply whose potential as a malleable material is only just being realised.

In March 2016, there were 11,688 community pharmacies acting to serve the NHS in the UK with a total UK pharmacist population of around 61,000 souls. There is no secret that schools of pharmacy have overproduced pharmacists over the years leading to fears of unemployment. At approximately one third of the cost of a full time GP, is it not time to think about integrating pharmacists into the GP workforce?

For me, I do not want to employ a pill counter – I do not need one. What I really need is a GP but I cannot find or afford one. This is where Richard comes in. Richard is my friendly neighbourhood pharmacist. We started working together to optimise prescribing in my practice and it quickly dawned on me that Richard could do much more than this, so after a phone call to Richard’s indemnifier I gave him a stethoscope and we started to see patients together.

As a trainer, this was second nature to me and I quickly realised that the human body was second nature to Richard. Now, Richard is an integral part of my team. He sees, assesses and treats patients independently and I am sure with time he will understand complex patients and manage them just as I do.

The ability of this pharmacist seems only limited by our time to sit together and share learning and I know that he has learnt to use his education to diversify his practice according to the needs of the population. What I have learnt in return is that we already have an answer to our workforce crisis sitting in plain sight, should we choose to invest our time wisely.

‘There be gold in them there hills.’

Dr Dean Eggitt is a GP partner in South Yorkshire and medical secretary at Doncaster LMC

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Readers' comments (32)

  • I am uncertain about this entire project, employing pharmacists as cheap pretend gps seems intrinsically wrong to me
    It denigrates our raison d'etre and suggests to hmg that unlike greedy overpaid gps this body of professionals can replace doctors thus giving a solution to the chronic underfunding in primary care
    If I am sick I would prefer to see an experienced doctor over and above a pharmacist, if I needed an operation is unlikely a pharmacist would be tasked to do it, so why does hmg feel that gp can be done by anybody with a vaguely medical like degree?

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  • The problem is that Pharmacists have no formal training in this country to become 'Clinical Pharmacists' like elsewhere in the world. My experience of employing Pharmacists is that they are very variable regarding their individual ability and confidence in managing anything more than simple minor issues. Mind you nothing that formal training could not sort out.

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  • @8.31

    I agree with your sentiments, but the same process is already taking place in hospitals with trained up nurses replacing hospital doctors.

    It's all about improving productivity, which has taken place in other services. This could be replacing highly trained people with cheaper lower trained ones, or the use of computers and modern industrial robots.

    The problem is the whole of the capitalistic western economy is based on constantly improving productivity in order to increase profits / growth. The NHS is not 'currently' for profit, but the cost is a drain on the economy.

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  • doctordog.

    we should all embrace this, not feel threatened.
    pharmacists can provide very useful input, including, prescribing issues, medication reviews and queries, audit, managing long term problems etc etc

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  • "On top of this, GPs are expensive, demanding six figure sums for full time work".

    This is an LMC secretary speaking? I don't consider 100K for a full time GP expensive at all.

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  • Oh the joys of muddled thinking.

    As many hospitals have noted the use of 'nurse consultants' was borne out of desperation and has had significant negative impacts on the running of wards with often senior nurses moving into these roles.

    Pharmacists will do a job, they will create a body of work to justify an existence. Whilst their indemnity is subsidized by a GP.

    There is danger of large scale self deception if we think GP's can be replaced by 'apparently cheaper' individuals, the dangers of false economies are well documented.

    It is truly awful to see GPs contributing to this intellectual fraud.

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  • Cobblers

    Six figure sum for GPs?

    Attributed to Red Adair: "If you think it's expensive to hire a professional to do the job, wait until you hire an amateur".

    5 years dedicated to pharmacopeia makes you good at (hopefully) medicines and related. Not to the dealing with the unwell human being.

    This is the Noctor/Phoctor debate. Studies to date show them to be slow and unable to make decisions. Indeminity might well deal the death blow. Then it might be the end of all of us.

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  • We are getting it all wrong. If the front line is staffed with the inexperienced and risk averse then everything upstream will suffer. Just look at 111. Historically the high pay and esteem seem to go to those inhabiting the backwaters of medicine. It should be simple to reverse this, incentivise A+E/MAU/GP docs and watch the system improve.

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  • I could write a book on this subject but for the benefit of everyone's sanity, I will summarise.

    Pharmacists are highly intelligent, highly capable professionals. They are experts at managing medicines - from reconciling discharge summaries to managing ongoing audits. Their in depth knowledge of therapeutics means they have a significant role in polypharmacy so are potentially a huge asset for the elderly, especially in nursing homes.

    I think they should definitely be part of a primary care team as they are better than GPs at performing certain tasks.

    BUT there is a big BUT. They can assist with GP retention as they make the job more manageable and the days less long. However, I don't think they have a role in assisting recruitment.

    The reason? GPs seeing more patients in place of their medicines management admin is a sure pathway to burnout. We simply cannot see more patients. And I have grave reservations about anyone else examining and diagnosing without the required training attached to it.

    So I definitely think pharmacists can make our days easier. But no way are they the answer to the shortfall of GPs. Anyone who thinks they are, is really undervaluing our knowledge, skills and experience.

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  • Forgot to add - I have been the practice prescribing lead for 10 years and several members of my family trained in pharmacy

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  • So let me get this straight..... the 'hope' of our profession, our holy grail, our salvation, is actually getting another profession to bail us out, well that won't undermine our cause will it......mmmh the Royal College of General Pharmacy...... perhaps thats the plan, to franchise Euston square out as a Boots superstore (Probably be more profitable)......don't get me wrong, a pharmacist in the team is a great asset, but its not going to solve the recruitment crisis......I think the comparison of pharmacists with gold nuggets is over-egging it a bit, describing the future of UK general practice as floating like a lead balloon seems rather more apt....glass-half....hang on I can soon fix that :-)

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  • This comment has been moderated

  • Oops, apologies, left out a 'more' there....somewhere between westminster and than..... but more is good, more is a reminder.... bottoms up!

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  • And for anyone who thinks Virgin is a risk...... imagine if Boots thinks they can move into General practice..... heres how the profession of pharmacy got on once corporates got involved....
    https://www.theguardian.com/news/2016/apr/13/how-boots-went-rogue

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  • We've already tried this. It didn't work for a number of reasons. Firstly, you need a quite senior pharmacist to cope with the clinical stuff and they are less abundant that the inexperienced ones. Secondly, we need prescribers. Thirdly like all 'practitioners' they often add to your burden by requiring supervision and generating extra work e.g sending tasks back and forth. Fourthly it takes considerable resource to train them. Fifth, we have vicarious liability for them and their indemnity is not sorted out. Large claims are starting to come through the system against pharmacists.

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  • A quote from the above article....

    "Now Tony saw his workplace as a factory. “It’s a profit factory where we’re doing piecework,” he said. All these decades after university, his working life was suddenly dictated by people who had little respect for his education or his profession. “The standard of education of these managers … some of them can’t even spell prescription; they put ‘quiet’ when they mean quite.”“How can Boots call itself a healthcare company when it’s done this to me?”

    This could be a description of the modern NHS?........I suggest you all discourage your patients from using Boots until Boots pays tax...before I left the UK I used to educate my patients about this issue..after all,informed consent is important, now where has the Sommelier gone to?

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  • Indemnity is sorted for this cohort with a shopping list tick box proforma depending on the work they will be doing e.g telephone triage first contact costs £350 extra etc. (I have been through this with a pharmacist last week and seen it first hand)
    I could not see a problem with their indemnity costs although with the full fat package of what GP's tend to do it is nearer to the £2k for the year (bargain compared our costs but expensive for them as they usually pay £150 or so in the community)
    I agree variability on candidate but there are now postgraduate training courses at prestigious uni's (3 years long) that train these people into mini doctors. I have assisted on these and for example the level of clinical examination examined on the OSCE is MRCP standard!
    Experience is another matter and thats where good training on the shop floor comes in.
    lets face it there is no one else to do this work and if you think there is going to be a large lottery windfall for us GP's from the government fahhhgetttabbbouttiiittt! so best get on it and support if you are a young/middle aged GP

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  • So as I see it:
    Your kid either doesn't have the grades or masochistic tendency to accumulate 6 years tuition and maintenance fees so guess what........
    Daddy I now realise that 2 years will get me a pa job at over 50 grand a year or once I get my quasi medical degree I can apply for various noctor jobs throughout the NHS......
    Why would an astute 18 yo do a medical degree anymore as it is no longer needed to be employed as a noctor in the current nhscsetup
    RIP medical schools, you are no longer needed as we will get our noctors from elsewhere....

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  • GP recruitment | Locum GP13 Jul 2017 2:36pm

    Indemnity is certainly not sorted

    We send out our employed pharmacists for various drug trial projects and have to take the entire indemnity bill associated with these projects.

    The costs of single trial projects can be very substantial.

    The cost you may seeing is a false one, essentially any complaint within primary care tends to bypass non doctors for historical reasons. indemnity organisations are now factoring in those costs in the GPs indemnity bills.

    We are seeing huge insurance cost rises for drug trials where clinicians ( typically from hospital CRFs ) are now being asked to declare their involvement in trial projects where historically this was covered by terms of hospital/crown indemnity.

    For pharma the insurance costs can be costed into the project design, however it is entirely unreasonable to suppose that individual Gps could ever take on the costs and the risks long term.

    Especially when you consider the training of GPs /junior drs and the disaster in planning is the responsibility of HEE/NHSE etc

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  • A Practice with 4000 patients unable to afford a full time Nurse and/ or a full time second GP has really got to be completely insane to try to fit in a Pharmacist of dubious efficacy. This promotion of PA/Pharmacists/NPs etc is strange - How can Practices afford these if they can't afford frontline staff and are paid only for 80% of their list sizes reduced every year by 100 patients for 3 to 4 successive years despite no significant change in list size.

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  • Dear Nigel (ed) and all readers- my response to being moderated.
    I would just like to point out that anyone who is 'criticised' could find such criticism 'insulting', but I would quote Abraham Lincoln, "Our critics are our friends, they show us our weaknesses'. It seems ironic that when we are abused in the press and by irrational patients on a daily basis, and expected to be able to cope with it by our college, that those leading our profession seem to be exempt from the rough and tumble that accompanies leadership in this otherwise great publication, if this is indeed what my 'moderation' relates too.
    I spent many years working in a private company overseas. Their attitude was that if you are 'offended' by something then it is your problem, not the 'offenders', as you have been unable to depersonalise it, and we were challenged on what 'being offended' actually means. We choose to be offended at some level, It is an internal emotion. We have control over it. Or, as the Dalai Lama puts it- 'the people we find challenging are those we should embrace as these are the people who come into our lives to teach us our people skills'. This approach allowed for free and frank expression of opinions, and interestingly, I found it a much more productive strategy than walking on egg shells and political correctness. This wasn't meant to engender downright rudeness, but meant to help foster our skills when challenged by 'awkward' individuals so that we wouldn't become stressed in these pressurised situations and remained in control at all times. It also meant meeting were much more time efficient, and less ambiguous.
    Politics is a nasty game, our leaders need to be up to the task to fight for our profession. I take the reporting as being 'offended' as suggestive of an inability to cope in a pressurised environment and further reason to question if those who are 'offended' are actually emotionally robust enough for the role.
    I had a patient cause me of being a 'dirty filthy child molestor' today out of the blue. How should I have responded? And should I be offended? (And no Im not before anyone asks :-)
    I don't think the comments which have been moderated are anywhere near the kind of abuse myself and many of my colleagues face on a daily basis yet we have to deal with these day to day with no recourse in most circumstances. So why is there so much moderation in this forum? I think a discussion around this issue would be helpful.
    I think Vinci Ho has the right idea..... "I might not agree with you, but I will defend to the death your right to say it"......

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  • What a sad tale. We have to be very clear about this sort of anecdote.

    This example is a doctor on the cheap and is worse for patients. Essentially you're saying that everything I do can be done by a pharmacist; just give them a stethoscope and a tutorial or two.

    I am embarrassed this man is an elected GP representative.

    Shame on you.

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  • We must realise that the only reason that there is a drive to replace doctors is because the desire by the powers to be is to reduce costs and improve productivity.

    History has shown that when less qualified people are trained up to perform functions above their normal workstation it is fine for a short while. However when these people are then used to replace more expensive personnel, in time those less qualified people end up demanding more money per hour until there is little difference in pay between themselves and the people they are replacing. As an example in the United States today there is for less pay differential between highly trained nurses and family physicians. Nurses pay has been increasing while that of family physicians has been decreasing.

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  • Thank you MC Hammer 15 Jul 2017 @ 8:16am. Spot on.
    Doctors particularly GPs are their own worst enemy.
    How can any GP in their right mind think that simply giving a pharmacist a stethoscope and a few hours of observation makes them a doctor. Dr Eggitt do you think that what GPs do is so simplistic that this will suffice as 'training' to be a GP? Please do not ridicule the years of training and hard work it takes to become a doctor. Thank you.

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  • If general practice were to become 'contaminated' by too many nurses and pharmacists, the poor cost-effectiveness of the newcomers would not be so clear.
    It would be preferable if primary care systems staffed by paramedicals (presumably with a token supervisory doctor) were entirely separate, then they could be shown either to be the cost-effective, efficient future of primary care, or, as I suspect, an inherently dangerous, inefficient and ultimately more expensive mess. I gather that there are one or two practices in the Grampian area largely staffed by nurses with the latter outcome.

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  • My general experince, from patients accounts of the advice they have been given by pharmacists before they come to see me, and of my contribution to the training of a clinical pharmacist, is that the majority of pharmacists have only the sketchiest understanding of clinical medicine and are a million miles from being able to stand in place of an experienced GP. On the other hand their professional expertise, in areas of primary care to which they are suited by virtue of their training and experience is very much to be welcomed.

    But substitute GS? Never.

    They'll miss us when they've driven us all away.

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  • Pharmacists are excellent business people , I assume any savings by HMG will be short lived

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  • Or you could stop experienced GPs leaving the NHS. Fix unlimited risk of complaints and rising insurance premiums.

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  • Dr Eggitt may wish to consider the points made to a similarly foolish article in the BMJ a few years ago:

    http://careers.bmj.com/careers/advice/view-rapid-responses.html?id=20020302

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  • Right, my experience of pharmacists is they they just increase my work by sending every patient who tries to buy anthisan to me for antibiotics for 'infected insect bites' ditto for every mum with a snotty kid who tried to buy cough medicine - 'they need to see the doctor' plus those flippping medication reviews that sent the patient scurrying back to the doctor for every twinge and ache, finger prick cholesterols etc, they seem to generate more work then they save!

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  • Dean Hello!
    Much to ponder in yr article
    I only work 1/2 days a week and not boss anymore
    How are things with you
    Rodney Mitchell

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  • Dr Dean Eggitt

    Dr Mitchell!

    My childhood hero!

    I'm glad to see that you are still practicing. Life is great and I'd love to hear from you / meet up / catch up.

    Email me! - Deaneggitt@hotmail.com

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