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At the heart of general practice since 1960

How our in-practice pharmacist has reduced GP workload

Dr Dev Malhotra explains how his pharmacist partner, Dipti Gandhi, has saved time, supported chronic disease management and enabled same-day repeat prescriptions

What we did

We are an inner-city practice in Croydon, south London, with a degree of deprivation and a large black and minority ethnic community. We look after approximately 17,500 patients.

In 2003, with the contract changes and the advent of the QOF, we decided that we needed support to administer the changes and maximise the benefits, so we employed a clinical pharmacist. She had a background in hospital medicine and the local primary care organisation, which meant she already understood local organisational issues from working alongside NHS managers. As the need for medicines management and chronic disease management increased, she became so valuable to us that we appointed her a partner in 2006.

Her current role is wide ranging and involves implementing and monitoring the QOF, LESs, DESs, and local incentive and prescribing schemes. In addition, she carries out medication reviews, optimises repeat prescribing and medicines reconciliation with patients and hospitals, manages long-term conditions and implements clinical trials in the practice. She is also an independent prescriber.

On a typical day she will undertake a hypertension and diabetes clinic independently, seeing 12 patients with 15-minute appointment times. This will be followed by repeat prescribing, including signing the scripts and sending them via EPS. The rest of her day will be spent on clinical organisational concerns.

Results

She has reduced workload for the GPs, as we do not spend so long on repeat prescribing and she independently runs our chronic disease management programme.

Without her our QOF scores would not be so high. She has been with us since the QOF’s inception, and from the beginning we received scores of around 1,050, while other practices near us received around 800.

We also have high-quality medicines management, with onsite medication reviews from a pharmacist’s perspective. Everyone on repeat medicine has an annual review. If they are on four or more medications they have a six-monthly review. We no longer prescribe specials and we robustly adhere to local and national guidelines. We also meet local prescribing incentives every year and use our repeat prescribing process to recall patients for the QOF and LESs. Most importantly, we now have a same-day turnaround for repeat prescriptions – usually around six hours.

Without our pharmacist we would not be involved in so many enhanced services. She set up the unplanned admissions DES and looks after our care home services.

The future

We have applied for funding through the NHS England pilot scheme for clinical pharmacists in general practice, which would give us the opportunity to delegate further services to new clinical pharmacists – for instance, a minor ailments service. In anticipation, we recently employed two further clinical pharmacists on a part-time basis. With the current recruitment and retention crisis, we envisage such developments will lessen the burden for GPs.

You may argue that some of these developments could be supported by other healthcare professionals, but our experience is that the skills of our clinical pharmacist are well suited to such a wide range of functions and roles. She also has a corporate mindset, which has been hugely important with the changes of the past 12 years. We have never come across anyone else with such a broad range of skills, both clinical and organisational, who was not medically qualified.

Dr Dev Malhotra is a GP in Croydon, south London

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Readers' comments (31)

  • We echo that here in Bristol at The Old School Surgery! Well done Dipti, hopefully soon all practices will realise the benefits of having a clinical pharmacist!

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  • Dr Malhotra and his partner make a lovely couple and I am sure it actively improved their effectiveness as a team. All the best and well done.

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  • I thinks its all good an well a pharmacist trying to do some of the very minor and inconsequential bits of work in the practice but expecting them to deal with anything more complex than checking a blood pressure (with an electric machine of course) would be dangerous any more than I would be able to do their job of counting tablets out and selling chewing gum.

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  • Anon GP at 3.59 - why do your comments have to be so offensive

    Sessional GP at 3.05 - is this the correct media to raise such issues?

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  • Anonymous | GP Partner 19 Nov 2015 3:59pm

    As a pharmacist, I am of the opinion that we are not as clinical as we possibly should be. But what we are is efficient, patient focused and hard working. This skill set alone is the reason why many of the roles you have kept for yourself and have in my opinion been generously rewarded for, will be lost to more willing providers (not just pharmacists).

    GP's don't take blood, don't always write or read letters, don't give injections, don't do reviews, don't educate patients, don't do out of hours.

    Everyone's job involves an element of stuff that you don't want to do. I think you might have been found out.

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  • Generously rewarded? I nearly spat out my ice cream! Do you have any idea what we are paid for looking after the care needs for a complex elderly patient for a year? It is less than you would spend on insuring your cat!

    Chronic disease reviews - practice nurses can do it cheaper and are also trained to take bloods and dressings

    Repeat prescribing - if GPs are no longer doing this, do they have to see an additional 6 patients per day? Because it they are not, it is an expensive luxury

    Cost effective prescribing - as there are currently no practice penalties for expensive prescribing, then you are funding the CCG to stay within their prescribing budgets

    Strategic vision - isn't that what a manager is for?

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  • You're in the minority if you don't think you're well paid. From the bottom (Daily Mail) to the top (Agent Hunt). I was still working when you were trying to keep hold of your ice cream!

    I don't think a nurse, HCA or pharmacist is as good as a GP. I also don't think that a GP is as good as a specialist. But we don't get to see to a consultant each time we have a problem, we see the next guy down the chain (you). All I ask is that you have a little more respect for the next guy down the chain from you.

    You're also paid for patients that you never see, but nobody seems to remember that.

    You are an NHS provider. If you don't prescribe cost effectively then you are taking money out of the dwindling pot that you so desperately want to get your hands on. Prescribing cost effectively should not be dependent on whether you get paid to do so and I'm not going to pat you on the back for doing so. Where's your pride?

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  • Albert Boatman

    I agree entirely with Dr Nabi and as the saying goes if you pay peanuts you get monkeys . As for the amazing impact of this set up and trying it out in your own practice I suggest to see the comments of this beacon practice on NHS choice reviews many of which are about the terrible repeat prescribing system which is th one thing you would think they would be good at . I particularly would like to draw your attention to the one star comment of June 12th which mentions the pharmacist in the article particularly and their perceived impact on patient care .

    http://www.nhs.uk/Services/GP/ReviewsAndRatings/DefaultView.aspx?id=42447

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  • If anyone wants to know why young dynamic doctors have decided to give general practice a wide berth you need do no more than read 7:39.
    The brimming contempt for us evidenced there is so widespread why would anyone want to do it (because anyone can apparently)?

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  • When did general practice become such an unknown quantity? As someone with first hand experience, I can state that GPs certainly do take blood, both read and write letters, give injections, undertake reviews, educate patients and cover out-of-hours along with consulting, visiting, prescribing, arranging investigations, checking and acting on results, following up missed appointments, undertake palliative and end-of-life care, etc, etc. I find it hard to believe anyone would think otherwise - just what level of ignorance are we facing?

    Furthermore, it's not a question of good/better/best but of consulting the most appropriate person for the problem presented. GPs have breadth of knowledge while specialists have depth - it doesn't make one intrinsically better than the other.

    The payment per patient, even those we don't often see (very few) is because the system works like insurance, the idea being that there is a fixed level of income to allow for regular employment of staff and a degree of planning but with no control over how few of many times patients consult. If we were not paid for patients who don't need attention in any particular year, we would have to be paid per consultation for those who do. One cannot reasonably argue for a fixed payment for those who consult and no payment for those who don't.

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