Perceived obstacles to the integration of pharmacists into primary care

Participants identified several potential obstacles that need to be surmounted or removed to facilitate the integration of pharmacists into GP practices.

6.5.1 Funding and resources

Practice pharmacists, GPs and HoMM all considered that funding was a major barrier to increasing the time that pharmacists worked in practices. All practice pharmacists in this project were funded directly or indirectly by the CCG (usually from the drugs or management budget), so there was no direct payment from the GPs for the services provided by the pharmacists. The focus group pharmacists felt that GPs, therefore, had little idea of the cost of providing the current PP service and that this made pharmacists nervous about the future.

“I am employed by one of the practice again to help with the repeat prescribing, and when asked what my salary rate was, they almost fell over and said I don't suppose you accept any less would you.” PP C2

Many of the GPs interviewed had strategic input to the CCG, so they theoretically had access to the cost of the current practice pharmacist service, but two GPs described practice pharmacists as “expensive”. One went on to suggest that practice pharmacists were a

“luxury item” and thought that the commissioner of the service might question the value of a pharmacist compared to that of a nurse practitioner, although the GP did not know how the salaries compared.

“I suppose they're [PPs] still fairly expensive aren't they as well, as professionals go, the CCG might not see the value of them... I don't know whether a nurse prescriber and a practice pharmacist prescriber earn a similar salary or not?” GP C1

One other GP was more pragmatic and felt that the choice between a nurse and a

pharmacist depended on the needs of the practice at the time. He also felt that GPs did not invest in sufficient practice nurses and that this had to be addressed before they could consider a PP. The PPs were more direct about this issue and sceptical because nurse salaries were lower than those of pharmacists; nurses would be employed preferentially in the current financial climate.

Changes to GP funding streams via QoF (National Institute for Health and Care Excellence, 2016) were thought to be a threat to the future possibility of pharmacists being directly employed by GPs (independently of any CCG funding); the potential loss of GP income would make it less likely for GPs to be able to invest in a pharmacist to make savings.

Physical space within GP surgeries was also identified as a barrier limiting access to practices.

6.5.2 Value of practice pharmacists based on cost-savings

Another issue related to resources was the current focus on savings; the CCG emphasis was currently on cost saving through the QIPP agenda (Department of Health, 2010) and PPs felt that this was unsustainable given that savings were becoming harder to realise. GPs also considered this unsustainability as a risk.

“I would hope that they [PPs] would be maintained I think there's been a danger that they're seen as one of those luxury items that potentially is cut.” GP C1

The threat of removal of the current service provision was considered a backwards step by GPs in general. One GP was prepared to outline the potential impact on their practice of the loss of their practice pharmacist, including the likely cost implications.

“… my biggest fear is that my practice pharmacists will be taken away-not funded…which would be a large detriment… to general practice…I wouldn't be surprised if they were taken away-which would be paradoxical, I think it would end up- to save £50 an hour you'd lose

£100.” GP B2

6.5.3 Medical education and training

One of the GPs felt that their undergraduate training did not cover the role of pharmacists in primary care and so there was a lack of basic understanding of the benefits of having a pharmacist on their teams when they went into general practice. Practice pharmacists themselves felt that their role was poorly defined, not always related to a relevant

competency framework and that, although training opportunities were available, the training was not always relevant to the role. This view may have been exacerbated because of the withdrawal of centrally funded training for PPs, delivered by the NPC.

One HoMM suggested that confusion between the different sectors of the profession was a barrier, particularly where practice pharmacists were confused with community pharmacists.

Practice pharmacists and HoMM considered that practice pharmacists are significantly

different from community pharmacists, regarding their training and experience, to be differentiated as a separate group.

“The difference between the different strands of pharmacy: primary care, practice-based, community pharmacy. Every so often, I'll still see a paper that someone's written without talking to me that talks about community pharmacists, and I like to put my hand up and say,

"They're not community pharmacists. They're clinical pharmacists, and they're working in practice.” HoMM D

6.5.4 Salaried doctors

Salaried doctors have been replacing many retiring partners in GP practices, and this was considered a potential barrier to engagement with the PP and CCG because it was felt that a salaried doctor’s relationship with the business aspects of the practice was potentially

different to that of a partner. Salaried GPs might not be so likely to care about cost savings or act on the advice of a practice pharmacist, thereby reducing the value of the pharmacist to the practice. This was identified as an issue by both GPs and HoMM but interestingly not by pharmacists themselves.

“Because there's an issue from the practice’s point of view and there's also an issue from the engagement with the CCG … you've got salaried doctors who don't necessarily want to follow the formulary...” HoMM B

6.5.5 Practice pharmacists’ professional isolation

There was a sense of isolation from the rest of the pharmacy profession, in as much as the number of practice pharmacists was small. It was felt that there was little recognition of the role in the undergraduate course and, arguably until recently, within the professional body.

Since these views were expressed, the professional bodies for medicine and pharmacy and NHSE have increased the number of clinical pharmacists (PPs) and raised the profile of the role, both inside and outside the pharmacy profession. The NHSE pilot has addressed some

issues related to training and funding of pharmacists working with GPs. Health Education England is working to develop pharmacist clinical assessment and consultation skills (Health Education England, 2015a), and has funded independent prescribing courses for

pharmacists (Health Education England, 2017).