Is putting clinical pharmacists into general practice really an innovation?
Dr Kamal R. Mahtani writes
Declining resources, an ageing population, multi-morbidity and rising demands are just some of the reasons adding to an unsustainable workload in general practice. As the RCGP point out in their discussion paper, there is an urgent need to develop strategies that can successfully reduce the workload on general practice while minimising the risk to patients.
As part of this, the RCGP Blueprint for building the new deal for general practice included a request to allow GPs time to innovate as well as find ways to free up more time for direct patient care. Within that remit was a specific call to provide practices with funding to pilot clinical pharmacists working within general practices. NHS England, as part of the general practice workforce action plan, launched the Clinical Pharmacists in General Practice Pilot, backed by Health Education England, The Royal College of General Practitioners, British Medical Association’s GP Committee and Royal Pharmaceutical Society.
What is a clinical pharmacist and what do they do?
The NHS England pilot scheme will part-fund approximately 250 general practice clinical pharmacists (GPCPs) across England. However, it should be noted that only 40-50 of them will be at a senior level (based on the number of years of experience). As a minimum, a general practice clinical pharmacist will have completed a degree in pharmacy, be a member of the General Pharmaceutical Council (GPC) and had a minimum of two years working in the community or a hospital setting. They should ideally, also be a member of the Royal Pharmaceutical Society (RPS).
As part of their training, clinical pharmacists recruited into the pilot scheme will enter an 18-month general practice pharmacist training pathway, supported by the Centre for Pharmacy Postgraduate Education, consisting of specific learning themes. A key offering will be training to become a non-medical prescriber (NMP), although some pharmacists entering the scheme may already have this. Independent prescribers have the ability to prescribe all medicines including controlled drugs (unless for addiction treatment). All GP clinical pharmacists will be required to have clinical indemnity insurance, which most already have.
The skills and training of a GPCP are anticipated to impact directly on face to face patient care. The Royal Pharmaceutical Society have provided case studies as examples of this. A typical day of a fully integrated GP clinical pharmacist may begin with reviewing and issuing the repeat prescriptions requests, including liaising with patients or healthcare professionals on medication related issues. Some pharmacists also engage with clinical triage of patients either into other clinics or their own ones. These clinics may include condition and medication reviews, specifically around monitoring adherence and tolerability of drugs but also opportunities for deprescribing to reduce polypharmacy and adverse drug side effects. A clinical pharmacist may also also extend some of these roles to home visits or an extended hours service.
Evidence base for GP Clinical Pharmacists
The NHS England pilot scheme has a relatively small, but not unreasonable evidence base which tends to favour likely success. A systematic review of 38 randomised controlled trials that explored the role of pharmacists co-located within primary care settings, including general practice, favoured implementation. For the majority of studies, pharmacists were able to deliver a variety of interventions with most studies reporting positive effects in at least one clinical outcome. Despite several limitations (e.g. included study quality, use of surrogate end points, identification of English language studies only) the overall review conclusions were positive.
Other studies have also highlighted potential benefits to patient safety. The pharmacist-led information technology intervention for medication errors (PINCER) study, a large UK GP-based cluster randomized controlled trial, found that a pharmacist led intervention was effective in reducing a range of medication errors in general practice.
A similar scheme is being considered in Australia. A qualitative study of key stakeholders within an Australian general practice setting, found that patients generally felt comfortable seeing a GPCP, with a notion that they were an integrated part of the healthcare team. Professional relationships with colleagues (allied health team members, practice managers) were also found to be positive. A notable finding was the benefit of providing immediate reassurance and feedback to clinical colleagues specifically around medication issues. It is important to note however that the study highlighted logistical challenges such as availability of space as well as modifying GPs’ behavior, both of which will need to be considered by applicants for the current pilot.
Implementation, KPIs and anticipated clinical outcomes
Details for implementation of the scheme are available already with the submission window opening in September 2015 and an announcement for successful practices shortly after.
The NHS England pilot documentation has also outlined some of the indicative key performance indicators (KPIs) and anticipated outcome measures for this pilot. However, it will be up to individual applicants to make the case for KPIs relevant to their populations.
Real world evidence for implementation already exists. One example is a Cornwall based practice who started employing a full time practice pharmacist seven years ago with such success that three years later they employed a second part time pharmacist. Their business case makes for very interesting reading as they report savings (e.g. increased clinician capacity) that more than covered the cost of employing a GPCP (estimated at £35k to £45k). Whether this can be repeated across the pilot remains to be seen.
The long term vision of this pilot scheme should not be seen as a substitute for patients being able to see their GP nor a solution to the the 8000 more GPs that are needed by 2020. A budget of £15 million also means that only a handful of practices are likely to benefit from this pilot. Practices will also have to consider how they will fund the balance of the employment costs as well any on going costs.
It would be unsurprising, and to some degree understandable, for there to be some cynicism around this scheme. However, given current workloads, few would disagree that general practice is in need of change and support. So while constructive cynicism should not be ignored, neither should opportunities to innovate. The GP clinical pharmacists scheme may have some limitations, but any longer term opportunities to decrease GP workload and improve patient care, should evoke optimism and consideration.
My thanks to Ravi Sharma for independent advice on the scheme.
Dr Kamal R. Mahtani is a GP and Deputy Director Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences at the University of Oxford. He tweets at @krmahtani.
The views expressed above are those of the authors and not necessarily those of the employing/funding institutions, the NHS or Department of Health.