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Why I back the patient's right to decide death

Dr Peter Stott believes it is in the field of professional repeat prescribing that the true cost-effectiveness of

the practice pharmacist will ultimately be revealed

Pharmacists! On any one day you can both love them and hate them. On the one hand they're the only group who have the confidence to ring and complain they can't read your handwriting. On the other they can save you from some very embarrassing mistakes. Many pharmacists with a background in retail or hospital pharmacy are now moving into new jobs in GP practices. With a salary scale in the region of £20 per hour, they must not only bring benefits to patient care ­ they must also be cost-effective.

An evolving but confused role

The role of practice pharmacist has evolved from that of the health authority pharmacists who were performing prescribing analysis back in the early 1990s and who undertook a variety of diverse and wide-ranging tasks.

At that time, there was great variation in the structure and organisation of the health service and great variation in job titles grew up. This was further complicated by the fact that more than two-thirds of primary care pharmacists were 'portfolio workers' with more than one job. They still are.

The 2002 pharmacy workload census commissioned by the Royal Pharmaceutical Society showed most were combining their practice role with working locum sessions in retail or hospital pharmacies, or with working for the PCT2. As a result, the title 'primary care pharmacist' always meant different things to different people. It still remains muddled and ill-defined.

Nevertheless, a five-point model has been used to describe a gradually developing role in the practice1:

Level 1 educational outreach only

Level 2 sessional (eg paid by PCT to support a period of audit)

Level 3 consultancy (self-employed, several jobs)

Level 4 GP practice primary care pharmacist (salaried)

Level 5 health centre pharmacy and pharmacist (with dispensing and clinical roles).

Practice pharmacists are independent professionals working at levels three to five. Their focus is limited to the practice; they are part of the practice team, responsible to the partners, and their overall aim is to improve medicines management for the practice population.

Medicine management and nGMS

Medicines management is and will continue to be a major preoccupation for the Department of Health. Not only is it an area of practice where great improvements can be made, it is also a major cost area and one where mistakes result in large numbers of hospital admissions.

The new contract has defined a basic role for the practice pharmacist which centres upon medicines management and in particular upon repeat prescriptions. These constitute 60-75 per cent of all the prescriptions we issue and are our second highest cost activity after hospital referral. Studies have shown that every £1 spent on medication review by a pharmacist leads to £2 in savings on unnecessary costs of prescribed medicines3.

A total of 42 points (worth £3,150 in 2004/5 and £4,704 in 2005/6) are directly available for medicines management. Another 64 (worth £4,350 and £6,496 in 2005/6) are available within the clinical categories.

Financial incentives for medicines management are also made by PCTs under prescribing incentive schemes. These aim to reward good prescribing practice that is evidence-based, and vary from a few hundred up to several thousand pounds each year. Usually practices may use this money to develop patient services, for example by employing a pharmacist.

So it could be argued that effective use of the nGMS contract coupled with money from prescribing incentive schemes will substantially contribute to the salary of a part-time practice pharmacist.

What does a practice pharmacist do?

Practice pharmacy is still in its infancy and there are substantial differences in roles, but common activities are:

·Communicating with local retail pharmacists to ensure repeat prescribing is efficient and well-managed

·Structured medication reviews ­ face-to-face consultations with individual patients (known colloquially as 'brown bagging') to which patients bring all their prescribed and OTC medications, health foods and nutraceuticals

·Provision of patient education materials related to prescribed medication

·Defining and creating protocols, formularies and programmes of medication review

·Creating practice-based systems to achieve success in prescribing incentive schemes

·Working with difficult patients ­ medication reviews and falls-prevention work in care homes and for housebound patients.

·Dealing with day-to-day prescribing problems and contacting patients after

drug alerts

·Working as a clinical co-ordinator to ensure success

in gaining quality initiative points; as qualified health care professionals, pharmacists are able to

relate to patients and to direct them into management routines that less-qualified staff might find difficult.

·Practice audit, flagging up areas where improvement can be made.

The future ­ repeat prescribing

Perhaps the most exciting developments will come when more practice pharmacists become supplementary prescribers. Only around 400 pharmacists in the UK hold this qualification ­ most of them working in specialist hospital situations like anticoagulation, hypertension and lithium clinics.

But practice-based pharmacists are beginning to be trained. Supplementary prescribers can issue prescriptions from the whole BNF. The only stumbling block is that there must be a signed individual clinical management plan (ICMP) for each individual patient.

But once a practice is well-organised there is no reason why the development of ICMPs should not become an integral part of medication review. Once created, plans run indefinitely until there is a change in the patient's condition. Once your pharmacist is a supplementary prescriber, they can take over and improve the whole burden of repeat prescribing, freeing clinicians from one of the most time-consuming, tedious and burdensome activities in everyday general practice and one at which doctors are consummately poor.

It is in this field of professionalising repeat prescribing that I believe the true cost-efficacy of the practice pharmacist will ultimately be revealed.

nGMS points directly available for medicines management

CHD

CHD 9 Record of antiplatelet agent 7

CHD 10 record of ?-blocker 7

CHD 11 record of ACE inhibitor 7

Heart failure

LVD 3 Record of ACE inhibitor 10

Stroke

Stroke 9 Record of antiplatelet

agent 4

Diabetes

DM 15 Proteinuria; record of ACE inhibitor 3

Epilepsy

Epilepsy 3 medication review 4

Epilepsy 6 convulsion free 6

Mental health

MH 5 lithium levels 8

Records

Records 7 Medication on clinical records 1

Records 8 drug allergies 1

Records 9 link between drug and problem 4

Records 12 record of OTC prescribing 2

Medicines management

Med 1-10 42

In addition there are other nGMS

points partially related to medicines management, for example within the mental health category - 23 points

in total

References

1 Jesson J, Wilson K. Primary Care Pharmacists: a conceptual model.

Pharm J 1999; 263:62-4

2 Mullen R. Clarity of nomenclature is needed for pharmacists who work in primary care. The Pharmaceutical Journal 2003 271;7278:772

3 Stanford E. Face to face with elderly patients. Medicines Management 2002 1;6: 10-12

Peter Stott is a GP in Tadworth, Surrey

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