Significant developments for Practice Pharmacists

There have been increases in the demand for PPs because of the primary care workforce issues as previously discussed, and two related initiatives that were not announced until after the data collection phase of the project reported in this thesis had been completed. The developments are outlined in 1.6.1 and 1.6.2 and add weight to the further integration of pharmacists into general practice.

1.6.1 Royal Pharmaceutical Society and NHS Alliance round-table meeting

On the 30^th September 2014, the Royal Pharmaceutical Society (RPS) and NHS Alliance held a round table discussion with general practitioners (GP) and members of the public to address the workforce crisis in primary care. The report, published in October 2014 (NHS Alliance and Royal Pharmaceutical Society, 2014), acknowledged the background to the crisis and proposed that suitably qualified pharmacists should be recruited to “fill the gaps” in primary care due to GP recruitment problems and the increasing workload. The report suggested that pharmacists already working in GP practices have improved both working patterns and the provision of care. Patient feedback has been positive and many traditional GP roles have been taken on by pharmacists in order to release GP time.

The report asked a key question: “Why does employing a pharmacist in a GP practice remain an exception rather than the rule?” and identified a lack of understanding of the PP role and issues with funding and training. Some suggestions to address these barriers were provided in the report such as managed integration, formal business cases, education and sharing best practice.

The document also stated, “There are an increasing number of highly trained and skilled pharmacists emerging from university, yet not doing the jobs to match their skill level”. While both statements may be true, the PP role requires a level of experience and postgraduate education that is not normally attained by recently graduated pharmacists. As previously stated, the report also wanted to understand the value of pharmacists working in general practice, what training is required and how best to integrate pharmacists into the general practice teams.

1.6.2 National Health Service England Pilot

In 2015, NHS England announced a £15 million pilot (NHS England, 2015a) to facilitate and train pharmacists to work in GP practices and address the workforce issues in primary care.

Further details were given in a report commissioned by the RCGP, BMA NHS England and Health Education England. (RCGP et al., 2015b). The scheme was oversubscribed, and a further £16 million investment was announced in October 2015 (NHS England, 2015a) with further funding of over £112 million announced in 2016 (Sukkar, 2016). The pilot is underway and uses senior clinical pharmacists (also prescribers) to provide clinical supervision to several (unspecified) other clinical pharmacists working together in clusters or federations of practices for clinical and peer support. The pilot will fund the PPs on a reducing scale, 60%

for year one, 40% for year two and 20% for year 3 with a focus on medicines optimisation and achievement of indicative outcomes. These outcomes include freeing up GP time and improving access to care, communication across patient care pathways and numbers of medication reviews. Also, there are some disease-specific outcomes that are much more difficult to attribute to a single intervention in practice, such as a reduction in COPD

admission rates and CHD risk in high-risk patients. (RCGP et al., 2015b). The scheme has raised the profile of, and interest in, pharmacists supporting GPs in primary care, but not all pharmacists employed as a result of increased interest have undertaken the Pilot training or had significant previous experience in primary care (Mills, 2016). The Pilot includes a National Learning Pathway, “Developing clinical pharmacists in general practice,” that was developed in 2016 by CPPE (Centre for Pharmacy Postgraduate Education, 2016). The Pilot, including the training pathway, has yet to be formally evaluated. Primary Care

Commissioning has been engaged to prepare and support the pilot GP practices to embed the pharmacist into their teams (Primary Care Commissioning, 2016) and is using the NHS Sustainability Model in this regard (NHS Improvement, 2017). Primary Care Commissioning has recently published a series of case-studies that provides some indication of the success of the Pilot so far (Primary Care Commissioning, 2017). Most feedback has been positive, often related to saving GP time, with the pilot pharmacists involved in most of the roles reported in the literature, depending upon experience. Pilot pharmacists have also started to expand their roles into telephone consultations, polypharmacy clinics and home and care home visits. While acknowledging their vested interest in a favourable outcome, the PCC

have reported several problems which suggests that there are some integration issues that have not been fully addressed. This thesis project hopes to clarify these and suggest solutions.

The reported problems have included intrusion or encroachment into other HCP roles and a lack of patient understanding due to difficulties in explaining the role and purpose of the pharmacist in advance of appointment to the role. Part-time working has been problematic for some pharmacists, and there have been recruitment and pharmacist availability issues leading to some practices leaving the pilot. Training needs have been underestimated with some pharmacists requiring training in communication and integration skills. While

acknowledging that pharmacists are not replacing a GP, some practices felt pharmacists were expensive and that GP budgets were a limiting factor in pharmacist employment.