The perfect pre-reg pharmacist year!

Aamer Safdar

Aamer Safdar

 

IMAGINE the scenario…

It is your first day in your pre-reg year and you have slept badly because you are full of nerves and some trepidation about your first day. You have woken up early to make sure you get to work early to give a good impression. You have picked your best suit, or dress, and spruced yourself up as best you can. You get to the pharmacy and everyone is expecting you and your pharmacist is so pleasant to you, that you have this nice feeling inside your tummy; you know the feeling when you think life couldn’t be any better… and then the alarm clock goes off and you realise that this was a dream.

Your first day didn’t quite go to plan. While the pharmacy staff were expecting you, they didn’t quite know what to do with you as they needed someone to manage the counter. Your pharmacist is not your tutor and is a locum because it is summer time and your tutor is on holiday. You are a bag of nerves because although you worked in community pharmacy while at university, you haven’t worked in this pharmacy before. You manage to get through the day unscathed and are wondering if this is the right place for you and what the rest of the year will be like.

Preparation
Preparing for the pre-reg year is not just the responsibility of your tutor. Too many trainees turn up to their training year without having done any preparation themselves; this is not university and no-one will be spoonfeeding you, let’s get this clear from the outset. You should, at the very least, have read through the GPhC pre-reg manual before your training year starts. Even my own trainees come into their training year without having done this! Reading the GPhC manual will give you a heads up of what the year involves and what you can do yourself to make your year a successful one.

There is nothing wrong with guiding your tutor and taking some responsibility for your own training. Some tutors would be grateful that you have done this, while others may not like you telling them what to do, so don’t go in all guns blazing. Instead, take your time to see what your tutor is like and how they are planning to support you. I always ask my trainees how they would like me to support them, so that there is no misunderstanding.

All trainees are different and, as I always have more than one trainee, I work differently with each one depending on what they want or need. The Royal Pharmaceutical Society (RPS) have a pre-reg tutor guide and it is worth informing your tutor about this, because it has only recently been launched and your tutor may be unaware of this. In fact, you should consider joining the RPS yourself to take advantage of the support material that membership provides.

Planning
One of the first things you need to do is to go through and understand your training plan so that you know what the rest of the year will bring. Identify your training needs and discuss these with your tutor, because the training plan would have been written before you arrived and would not have been individualised to you. Some corporate companies have set training plans, but there is always some flexibility depending on what you need.

Remember it is in everyone’s best interests if you are up to speed with the basics of your job as quickly as possible. You will need to start by building your own foundations of skills and knowledge; get the basics right first and then go from there. In other words, learn to walk before you can run. It is all about becoming consciously incompetent; if you don’t know what this is that, then you haven’t read the GPhC manual!

Evidence
One of the most important aspects of your year is writing records of evidence. There is no right way to do these and it is important you discuss this with your tutor as s/he will be signing you off. Some tutors like a lot of detail in the records, while others are happy with less detail and will talk the records through with you. Make sure that you have written enough in your records so that you remember things months afterwards, in case you need them for later progress reviews. If your tutor doesn’t want you to write any records because they see you in practice every day write them for yourself anyway.

The exam
Lastly, far too many trainees start worrying about the pre-reg exam, the official title is the registration assessment, and think that the training year is all geared up to passing the exam. In my personal opinion this is complete rubbish. If you practice well during the year, think about the patients and the prescriptions you have been dealing with all year and keep up to date yourself with your clinical knowledge and problem solving skills you are continuously preparing for the exam. You might need to brush up on your calculations though and keep practising these.

So may trainees start thinking about the exam six months before the exam and starting to panic. When in your life have you started exam revision so early? Did you do this for your GCSEs, A levels, or university exams? I don’t think so. There is nothing wrong with starting early but build yourself up and don’t panic or get overly concerned. Don’t listen to your mates as they can sometimes make you nervous for no reason.

Communication
Most trainees have a tough and challenging year and learn a lot from it. There are always some who find that their experience is very bad and that they are being used as employees and not as trainees. In these instances don’t keep things to yourself and speak to someone. While it might feel as though you are on your own, there is a range of things you can do which includes speaking to your university lecturers, speaking to the GPhC (although this can be scary) and speaking to Pharmacist Support. It is important to share your experiences and not keep them bottled up.

The transition from student to pre-reg trainee and then to registered pharmacist is a big one and most trainees are able to do this if they are prepared, resilient and focussed on the outcome.

I hope that this blog has been of use and all the best for a successful training year!

Aamer Safdar is the principal pharmacist lead for education and development at Guy’s and St Thomas NHS Foundation Trust. He lectures at undergraduate and postgraduate levels at Kings College London and University College London School of Pharmacy and is a member of the Royal Pharmaceutical Society English Pharmacy Board. 

Follow Aamer @asafdar1

A patient view of pharmacy medication use reviews…pharmacists would do well to listen!

download

FRIDAY, 11.00am…

I am standing at the reception counter of my local pharmacy, waiting for my monthly prescription that the pharmacy ordered a few days ago. Janine, the technician, gets the bag from the storage area and shouts to the regular pharmacist:

“Hey! Tom! Do you want an MUR? Says here that she last had one eighteen months ago.”

“No, thanks!”

…comes the response.

“I reached my 400 about six weeks ago. I won’t be doing any more until April. Is there any new med on the prescription?

“Eh! Let me see …”

Janine answers…

“No, doesn’t look like there’s anything new this month.”

“In that case just hand it out,’ is the final response. “Let me go and check some blisters,”

as Tom wanders off…

Janine then hands me my bag with her usual courtesy and practised efficiency. However, I can’t help thinking about the short interchange between her and the pharmacist…

I know enough about pharmacy to be aware that an MUR is a Medicines Use Review and, having had several over the years, that it can be very useful in identifying problems with medicines use, side effects and other issues related to my health as a patient.

It seems strange that the pharmacist should be reluctant to have a discussion with me about my health and medicines. After all, a lot could have changed in the eighteen months since my last review.

But then I remember that pharmacies are paid for only 400 MURs annually. My annual review appears to have been noticed at the wrong time, when the pharmacist had reached his quota for the year, and was no longer interested in conducting MURs.

Of course this leads to other questions. Why exactly do pharmacists do these MURs?

Is it because of the financial benefits? (I can imagine that in order to generate a net profit equivalent to the £28 they get for each MUR they would need to sell goods worth a few hundred pounds; or dispense several prescriptions.)

If this is the prime driver then it leaves a bit of a sour taste in the mouth, as it makes them appear as little more than mercenaries using whatever financial incentives there might be in the health service to make money.

I would like to think that there are altruistic motivations for the provision of the service: that the pharmacists conduct MURs because they genuinely care for the health of patients.

However, if this were the case, would pharmacists stop doing them once they got to four hundred, as seems to have been the case in this instance?

I’m also fascinated that Tom completed his quota in early February. Was this because there was such a massive demand for the service that he couldn’t stretch it until the end of the year, or simply because he had some form of race to the line to get to the 400 as quickly as he could?

In all honesty, I have to admit, I have never personally requested an MUR from the pharmacist, nor have I heard anyone ask for one on all the occasions that I have been in pharmacies; hence I am inclined to believe that the pressure to get to 400 comes more from the pharmacist than the patient side. I stand to be corrected on this (and I hope I will), especially since my analysis is based on just my own experience.

There are, however, other factors that lead me to think that my experience might not be as isolated as I wish it to be.

Tom works for one of the large multiples and has, in previous conversations, expressed how target-driven the culture is within the overall organisation. He has told of the pressures he faces to meet daily, weekly and monthly targets around prescription items, services, sales and costs.

I fully appreciate that community pharmacies are businesses that need to turn a profit, but I think it is possible that in some instances the profit motive could override the genuine patient-care outlook. The premature completion of the quota and – perhaps – the withholding of the service from potential beneficiaries because there is not financial reward are suggestive of this.

Perhaps this is all symptomatic of a bigger trend: what I like to refer to as the commodification of health.

This is the propensity to value patients and health parameters in economic and financial terms rather than the perspective of lives saved, improvements in quality of life or some other tangible, practical measure of health. The value of the patient consequently becomes measured in terms of the financial benefit or cost to the professional.

It is a malady that afflicts not just some in the pharmacy profession, but doctors and politicians as well.

The GP contract, for instance, rewards patients according to the number of patients registered (patient-units as a cynical observer might argue) as well as whether certain parameters about those patients have been recorded.

For GPs therefore, the value of each patient-unit is in the income it brings in relation to QOF points plus flu jabs etc. Politicians, on the other hand, will view each patient-unit as a cost/liability, hence the current talk of crisis in the health service over an ageing population in the UK.

I am not so naïve as to be ignorant of the fact that community pharmacies and GP surgeries are private businesses that need to generate a profit for the owners. I believe health professionals perform an important role and should be fairly compensated for the work they do.

I do, however, think that it is important to have a reward system that places patient care at the forefront of the service, so that no patient that genuinely needs medical or pharmaceutical intervention is ignored because the pharmacist or doctor has reached some arbitrary target. Perhaps I shall offer some suggestions on such a reward system in a future post.

 

Pharmapatient is an anonymous patient based in England. She has written the book, “Life at the Receiving End: The Experiences and Views of an NHS Patient”, available on Amazon in both Paperback and Kindle format.  

Check out the Pharmapatient blog.

Follow Pharmapatient @pharmapatient

* The above opinion piece is a result of a Twitter conversation between Pharmapatient and Johnathan Laird(@JohnathanLaird). Pharmapatient would like to thank Johnathan for reaching out to hear the views of a patient and for kindly hosting this guest blog post which is an excellent blog for all things pharmacy-related in the UK.

 

The Scottish Electronic Minor Ailments Scheme is a wee gem…Here’s why!

Johnathan Laird

Johnathan Laird

 

THE electronic minor ailments scheme (EMAS) is a scheme that as a community pharmacist I feel lucky to be empowered to deliver. EMAS is in my view a world leading service delivered to patients by expert pharmacists right at the heart of the community across Scotland.

Over 900,000 people have registered on the minor ailments service since 2006, and £110 million could be saved Scotland wide by treating common illnesses in community pharmacy. Evidence of this can be found in the Minor Ailment Study (MINA) conducted by Dr Margaret Watson from the University of Aberdeen in collaboration with colleagues from NHS Grampian and the University of East Anglia in 2014.

The service is offered from all community pharmacies across Scotland, and to access eligible patients must simply present to their local pharmacist with a minor ailment. Upon presentation the patient is registered electronically. A consultation with a pharmacist, in the vast majority of cases within minutes and almost exclusively without an appointment, then follows. Nearly all pharmacies now have private consultation areas which are widely used for EMAS consultations. Once assessed he service allows the pharmacist to supply a range of products and/or advice on prescription or refer where appropriate. EMAS has many benefits for both patient and professional.

For the patient, this is what they want and need at this moment. Critically our patient does not initially visit the GP or worse a secondary care setting. Instead the patient naturally thinks of the pharmacy as the first port of call for health concerns. I agree that the competence of community pharmacists, myself included, needs to evolve and improve but this service makes great use of the expertise there already.

Let’s begin with why the service is good for the patient by considering a few typical patients that I typically encounter in the community pharmacy. The first example of an EMAS patient is the teething, sniffly, colicky baby. This patient is usually just going through the normal motions of the first year of life. In the vast majority of cases the child will not require medical attention but may benefit from symptomatic treatment for these common ailments. Perhaps more importantly the support, reassurance and holistic care that the pharmacist delivers for the child’s mother on these regular pharmacy visits is invaluable.

My second example is the pregnant lady who presents with heartburn. Preventing a GP appointment by supplying an antacid to ease these short term self limiting symptoms of heartburn in pregnancy is great for the patient and makes sense for the health service too.
It’s not always about treatment. In fact I often use my good relationships and frequent contacts with patients to make useful referrals. The patient who makes repeated requests for a cough remedy is a common example of a potential area of referral as part of the EMAS scheme. Making more and more meaningful, well-informed referrals builds confidence in the growing competence of community pharmacists.
Other ailments that can be treated are included in the EMAS leaflet. However, most self-limiting conditions can be treated through the service.

Patients are encouraged to use community pharmacy first as a destination for advice or treatment. This happens naturally because the community pharmacy network in Scotland is so far reaching. Community pharmacies are located throughout the land in rural and urban locations. For a patient this is good news because in terms of accessibility there are no problems.

From a professional point of view EMAS is excellent because the pharmacy contractor is paid according to the number of patients registered with their pharmacy. Registrations lapse after a year if the service is not used by a particular patient. The important aspect here is a step towards payment of community pharmacists for supporting a registered population of patients so there is no incentive for the professional to over supply medication.
The good news is that the Royal Pharmaceutical Society and also Community Pharmacy Scotland support the service. In fact I was delighted to read in Community Pharmacy Scotland’s latest manifesto that the body representing contractors across Scotland were advocating an extension of the service to make better use of patient group directions similar to those used for chloramphenicol.
I would like my EMAS consultations to be recorded in the patient record for the rest of the multidisciplinary team to see. Seamless continuous care is critical nowadays so something as simple as a coded record in the patient journal about a pharmacist consultation would be very helpful. Perhaps the service will evolve towards this capability in the future.
EMAS is only one part of the community pharmacy contract in Scotland. I am happy to say that in my view it is a great way of beginning to release the ability of community pharmacists to support patients better now and into the future.
I would urge my English, Welsh and Northern Irish colleagues to look north to Scotland to see how useful a service like this can be.

Johnathan Laird is a community pharmacist independent prescriber with a special interest in asthma. He is based in Aberdeen.

Follow Johnathan @JohnathanLaird

Pharmacy can save the NHS…can’t it?

Graham Phillips

Graham Phillips

 

AS part of his reforms, former Secretary of State for Health, Andrew Lansley aimed to remove the NHS from “the tyranny of the political cycle”. However, the recent party conference season has seen undeliverable promises of more GPs, more nurses and easier access to primary care, from all parties.

These promises were made despite a reported £30 billion funding shortfall. It costs upwards of £500,000 to train a GP, takes the best part of a decade, and then they expect an annual income above £100,000. The Royal College of General Practitioners says we need another 16,000 GPs just to cope with the current workload. It’s simply, patently, unaffordable. Even if the NHS had the cash, it doesn’t have the time.
Meanwhile, there is a crisis. One of my local GP practices has effectively collapsed due to its inability to recruit doctors. A second has the workload for three GPs but cannot recruit a third partner, or even find a locum.

But the NHS is actually very efficient by world standards. It is arguable that most of the efficiencies have already been realised. Small, incremental changes won’t cut it! We need a paradigm shift – one that takes far greater advantage of community pharmacy.

Pharmacists are perfectly placed to help relieve both the financial and GP recruitment crises, and we are ready, willing and able to start work today. These days, pharmacists undergo thorough clinical training, over five years.

Although we have a desperate shortage of GPs, we have a relative over-production of pharmacists. I use the term ‘relative’ because it is relative to the traditional ‘safe supply’ or core dispensing role. Pharmacists could do so much more – and we will need the extra pharmacists to carry-out additional services.

A few thousand freshly-minted, eager and highly-qualified professionals could literally ‘save the NHS’. They could be trained as prescribers in six months and then run clinics and common-ailment schemes in GP surgeries or pharmacies. They could also work as healthy-living pharmacists and improve the public’s health.

The entire community pharmacy service costs less than £3 billion. The NHS spends around £12 billion on prescribed drugs (half of which are never consumed). Simply put, community pharmacy is an amazing bargain for the NHS.

A modest additional investment would ensure that each pharmacy has more than one pharmacist for some or all of the time, depending on how busy it is and how many services it provides. An increase in pharmacy funding would pay massive dividends in terms of improved use of medicines, improving the public’s health, reducing costs in secondary care, and taking the pressure off the GP network. Evidence shows that every NHS pound spent in the pharmacy saves £2 in the surgery, and at least £5 in secondary care.

GPs warn of stress and burnout, yet around 57 million GP appointments each year are for common ailments that could be handled by community pharmacists. Not only would it free-up all those GP appointments, it would save the NHS around £100 million, because pharmacists are less expensive than GPs.

Yet despite substantial evidence that these ‘pharmacy-first’ schemes work, showing high patient satisfaction levels and low re-consultation rates, they remain few and far between. The pharmacy profession has argued that the NHS should commission a common-ailments service nationally (the Scottish NHS has already done so), yet these calls have fallen on deaf ears. Why?

Evidence shows that 12 to 15 per cent of hospital admissions are directly related to prescribed drugs. Roughly half are due to complex interactions between a cocktail of prescribed drugs, prescribed in response to a plethora of concurrent disease states. The other half is due to poor compliance.

Patients are highly resistant to taking their medicines consistently, or at all. The drugs are wasted and patients don’t get the benefit, so morbidity increases and NHS costs rise. This is true for all long-term conditions: even HIV and transplant patients are poorly compliant. There is plenty of evidence that pharmacists can make a cost-effective difference if commissioned to do so.

But the NHS locality-based commissioning system overwhelmingly ‘gates’ pharmacy out. The solution is to add core medicines optimisation and public health services to the pharmacy national contract, and to align the community pharmacy contract to that of GPs. This would deliver the pace and scale of change the NHS needs. Instead of 150 different smoking-cessation services, let’s have one, outcome-driven and based on the quality and outcomes framework.

Besides smoking cessation, we should commission alcohol, drug addiction, weight management and sexual health services nationally through the pharmacy contract, plus a common-ailments service like the one in Scotland. That would free-up local resources to commission specific local services.

The pharmacy profession has an evidence base and widespread support for extending our contribution. We now need to up the ante and bang the drum for pharmacy and the NHS. But the best advocates are not pharmacists, they are patients and other professional colleagues. If, like me, you believe pharmacy could (help) save the NHS, please, please join the campaign for us to do so.

Graham Phillips is a community pharmacy owner based in Hertfordshire 

Follow Graham @grahamsphillips

The community pharmacy cuts are coming…Is it evolution or extinction?

Mohammed Ibrahim

Mohammed Ibrahim

 

ARE we going allow the slow erosion of high street pharmacy in to extinction? Or, could there be an alternative future?

I am a clinical pharmacist with a passion for community pharmacy, so here’s my point of view.

Listening to the pharmacy press and national pharmacy representatives, it seems that there is a likelihood of more cuts in the future as well as the expected 6% funding cut for community pharmacy this year.

So what does this mean for high street pharmacy, as we know it?

Will we shrink into dispensing factories reliant on NHS funding, with poor staffing and increasing workloads, or, will we evolve into accessible healthcare professionals on the High Street?

Speaking with contractor colleagues, in both small independents and large multiples, it seems that there is a sense of impending doom. Some are talking of freezing staffing levels and potentially reducing training and wage reductions for their existing staff, whilst others are thinking about cutting free services such as Monitored Dosage Systems (MDS) and prescription delivery.

Is the future of pharmacy really as bleak as this?

While the funding cuts have not yet been finalised, it is likely that they are inevitable and high street pharmacy will need to brace itself for what is certain to come. As a pharmacy contractor I completely understand the impact these cuts will have on the existing pharmacy business model, and, I fully support the protests against the cuts.

However, perhaps the 6% cut is a wake-up call for pharmacists. Indeed it could allow us recognise our own potential and shape the future of our profession, before it is shaped for us by those who don’t understand the role of pharmacy at the heart of the community.

We have been protesting for many years that pharmacist’s skills are under-utilised, and, those with clinical and independent prescribing (IP) qualifications don’t have a recognised role in the community. Up until 2015 there was no clear career structure for pharmacist IPs in the community, and the announcement to support pharmacists working alongside GPs was well overdue. Finally, we see that pharmacists are being recognised in primary care as professionals that make a valuable contribution to the clinical care of patients, other than simply supporting medicines optimisation initiatives.

But wait a minute, these pharmacists that are now working in GP practices, are they not the same ones that either worked or indeed continue to work in community pharmacy? Are those in community pharmacy not able to contribute to the clinical care of patients too? The advent of Summary Care Records (SCR) access, can allow pharmacists to play an even more crucial role in the clinical care of patients.

Whilst closure of some community pharmacies may be inevitable as a result of these cuts, I am optimistic, and I believe that pharmacies that are willing to embrace the challenges and re-think their existing model of service will survive, and possibly even thrive in the future.

I fear that the pharmacists who continue to think of their community pharmacy as simply a supplier of medicines and OTC products will have their days well and truly numbered. On the other hand, pharmacists who recognise their ability to deliver enhanced services in the most professional manner, and, are not totally reliant on NHS dispensing volume will indeed survive and could even thrive in the brave new world. This means that waiting for the NHS to commission services from pharmacy is no longer an option.

I believe that we need to take the bull by the horns and invest in our high street pharmacies to provide enhanced services that people would be willing to pay for…. I hear what you’re thinking, “…but our patients don’t pay for anything.” That may be true now, but is it possible, that people, who can afford to do so, would pay for a service that offers them convenience and saves them time? Perhaps we need to seriously consider provision of private services, either as independent prescribers or through patient group directions (PGDs), until such a time that the NHS is ready to fund such services through community pharmacy. We must not forget that high street pharmacy has a significant strength of accessibility. This may mean investment in your pharmacy so that it meets patients’ expectations, but isn’t that an investment worth making?

It is apparent that the government wants to see a change in community pharmacy with a drive to increasing efficiency in dispensing so that pharmacist time is freed up to provide patient centred care in the community. Whilst there is no definitive additional funding for services, pharmacists are finally recognised to do more than dispense prescriptions and perhaps this is an opportunity for us to take the reins and demonstrate our value to our patients too.

It would be interesting to see if other pharmacists share my thoughts; or is there another option for high street pharmacy, or indeed community pharmacy in general.

Mohammed Ibrahim is consultant pharmacist, pharmacy Contractor and clinical services director at RxAdvisor.co.uk

Follow Mohammed @Rx_Advisor