‘Pharmacy First’ a first for pharmacy

 

It’s tough out there in community pharmacy. To deny this fact is absurd. That said there is a ray of hope for the sector.

 

Once again, these green shoots and genuine leadership are emerging from Scotland.

 

For eight years of my career, I was a community pharmacist in Scotland. That time was spent running a community pharmacy in a rural location. The contract sustaining said community pharmacy, and all the others in Scotland at that time, was based largely on dispensing revenue. My paymasters at the time were not much fussed on remuneration from activities too far removed from the dispensing process.

 

More was more.

 

The perpetual conundrum for community pharmacy.

 

How to withdraw gently from a growingly inhibitive dispensing volume-driven contractual arrangement?

 

Interestingly the pinch point for the community pharmacy network in Scotland of late has not been funding, which has remained relatively flat but instead pressures on their workforce. The challenge has pivoted from one of funding to one of creating an attractive career option for young pharmacists entering the profession and of course unleashing the talent of the pharmacists in our community pharmacy network.

 

In January this year, the Chief Pharmaceutical Officer for Scotland Rose Marie Parr wrote a letter referring to the new NHS Pharmacy First service which is to be implemented from April 2020.

 

The Scottish Government’s Programme for Government 2018/19 committed to increase access to community pharmacy services by developing and implementing a redesigned minor ailment and common conditions service available to all. Our focus was on increasing access to community pharmacy as the first port of call for managing self-limiting illnesses and supporting self-management of stable long term conditions in and out of hours and to improve pharmaceutical care and contribute to the multi-disciplinary team.

 

It is intended that the redesigned service will replace the current Minor Ailment Service and current Pharmacy First services and will commence in all community pharmacies from April 2020. Implementation of the service will be supported by a range of materials and approaches to raise awareness amongst members of the public, pharmacy staff and other healthcare professionals.

 

A new remuneration model will be introduced from April 2020. This will replace the existing capitation model and will move to an activity based model, where the pharmacy team will be remunerated for the activity undertaken and reimbursed for dispensed items.

 

The activity will be based on Advice: Referral: Supply. There will be increased eligibility and access to the service which, together with the remuneration model changes, will necessitate changes to operational practices and how pharmacy teams interact with members of the public.

 

And there it is. Just like that the future beckoned.

 

The exciting element of the Pharmacy First service for me is not the initial setup phase, which has been executed brilliantly so far by Community Pharmacy Scotland colleagues, but rather the opportunities that now will emerge. Namely the prospect of making it the norm that pharmacist independent prescribers will operate ubiquitously across the Scottish community pharmacy network.

 

Moves have already been made by the Scottish Government to prepare the workforce for these changes but the work of Sam Falconer demonstrates that the innovators in Scotland are impatient to get going.

 

That’s the pot of gold at the end of the rainbow.

 

And many will sniff and ask:

 

Where’s the money?

 

Well, the short answer is that the money will come to deliver the service and the emerging model of payment looks as good if not better than the minor ailments deal. The existing capitation model will be replaced and will move to an activity-based model. In this model, the community pharmacy team will be remunerated for the activity undertaken and reimbursed for dispensed items.  The activity will be based on:

 

Advice: Referral: Supply.

 

But the real gold is the fact that community pharmacy in Scotland has the potential to develop and embed a compelling pharmaceutical care driven value proposition with the patient and pharmacist at the centre. If we get this right the value proposition offered to Government on one side of the market and people accessing the service on the other is so compelling that it would be daft not to invest and build further for years to come.

 

The bottom line ethos behind this new Pharmacy First endeavour will be the chance to harness the clinical expertise of community pharmacists. For years this work has gone unrecorded and therefore largely politically unnoticed. I think the pressure to gain widespread read/write access to the patient record will shortly become inevitable. The safe and effective delivery of a service like Pharmacy First needs a joined-up technology solution.

 

So we have the prospect of a joined-up, simplified and universally accessible community pharmacy service to enable pharmacists to make the most of the environment within which they exist, our local communities.

 

And what of the future. Well here is where colleagues at Community Pharmacy Scotland have shown some genuine vision and leadership. I’ll give the last word to them:

 

It is our intention that, in the long term, every pharmacy in Scotland will be able to offer a common clinical conditions service utilising the IP skillset and advanced clinical training. This offering would sit ‘on top’ of the Pharmacy First service, and in time will negate the need for any PGDs.

 

Pretty cool I reckon.

 

Johnathan Laird is a pharmacist who has said that if any PIP reader can find a better community pharmacy initiative than Pharmacy First in the world he will eat his BNF.

 

GPhC outline five key areas to consider before prescribing

 

 

The Council of the GPhC has approved new guidance for pharmacist prescribers to ensure that they provide safe and effective care when prescribing.

 

The Guidance for pharmacist prescribers covers five key areas that pharmacist prescribers must consider in order to prescribe safely and effectively. These are:

 

  1. Taking responsibility for prescribing safely.
  2. Keeping up to date and prescribing within their level of competence.
  3. Working in partnership with other healthcare professionals and persons seeking care.
  4. Prescribing considerations and clinic judgement.
  5. Raising concerns.

 

In response to feedback from a public consultation earlier this year, the GPhC has made a number of changes to their initial proposals, including adding further examples of prescribing in different settings and strengthening the guidance in relation to online prescribing of high-risk medicines.

 

The guidance emphasises that pharmacist prescribers must be able to justify their decisions and use their professional judgement in the best interests of the person receiving care, in all contexts, for example when providing a pharmacy service online or when working as part of a multidisciplinary team in a hospital, or in a community mental health team.

 

The guidance also sets out when prescribers should consider whether any extra safeguards are needed, for example, when prescribing antibiotics online or medicines likely to be abused or misused such as opioids.

 

Included within the guidance are a range of key questions that prescribers should ask themselves when prescribing in order to ensure they are providing person-centred and safe and effective care. The GPhC has also included links to other sources of relevant information and guidance, including from other regulators.

 

As of 20 November 2019, there are 58,085 pharmacists on our register, of which 9,142 are also independent prescribers.

 

Duncan Rudkin, Chief Executive of the GPhC said:

 

“This new guidance comes at a time when we are seeing rapid growth in the number of pharmacist prescribers working across a variety of settings throughout Great Britain. We have seen the number of prescribers on our register double since 2016. This new guidance clearly outlines what they need to consider in order to provide safe and effective patient-centred care.

 

“Furthermore, the guidance sets out the responsibilities of organisations that employ pharmacist prescribers, including having risk management and governance arrangements in place to protect patient safety.”

 

You can read the new guidance here.

 

Pharmacist prescribing will continue to be risky if we don’t get the basics right

Johnathan Laird MRPharmS(IP)

 

Like so many others recently I took the leap to the promised land of general practice. I have not really written about my experience of working in there largely because until now (2 years in) I had my head down finding my feet in this devilishly complex yet interesting role.

 

Do I love it? Hell yes but I still want to own a community pharmacy someday. It’s where I feel most professionally at home.

 

I thought it might be interesting to follow my blog on community pharmacy prescribing by drawing some comparisons with my experience so far working as a prescribing pharmacist in general practice.

 

The first thing I have to mention is the culture. The standards of practise are extremely high and the issues dealt with are complex but there is no emphasis on targets. Rather a collective team effort to get the work done. As many reading this will fully understand this is completely at odds with working in many areas of community pharmacy.

 

And this is when my life changed. This bit is important. For the first time since qualifying as a pharmacist, I no longer felt I had to apologise for delivering excellent pharmaceutical care. On a personal level, the psychological impact of no longer working in the hamster wheel of community pharmacy management took about a year to resolve. And in that time the practice team made me feel welcome but they also took myself and my other two pharmacist colleagues under their wing.

 

I began prescribing in this role from day one. It was expected and that was fine. My day is split in two. Morning involves hospital discharges, medication reviews and supporting the non-clinical team to resolve queries swiftly. My excellent practice manager had the foresight to plonk us pharmacists right in the centre of the admin area. We remain at the heart of all goings-on in that space and are on hand to support as necessary.

 

The detail about the environment is important because I went from an isolated pressurised situation where I was trying to do the odd bit of largely piecemeal prescribing to being at the centre of operations in a reasonably large multidisciplinary team. I do some prescribing in the morning to help these processes run smoothly but most of my prescribing activity happens in the afternoon.

 

The afternoons are my favourite part of the job. I run an ‘on the day’ clinic. Common clinical conditions are triaged to me and off I go. The level of supervision here may be of interest to others. Each of the GP partners took a turn at sitting in and coaching me when I joined the practice. This support was weaned away. Now the GPs are on hand to back me up if needed. Two years in I thankfully need less help but I will often refer especially if I spot something potentially serious.

 

And that is an important point because without the basic validated levels of competence how would a newly qualified PIP know what they were spotting or missing?

 

Without this level of supervision, even the best PIP in the country will be risky in my view. It’s about having insight into what you are doing, the consequences of your actions and the impact of those actions on the patient now and into the future. I suspect my medical colleagues would agree and that view will most probably be formed based on hard-earned competence after time served through many years of training to become a GP.

 

The practice team didn’t stop there though with the support. I have regular clinical update training sessions with the partners. We have a regular pharmacist and more recently multidisciplinary meetings. We cover practical systems based topics but now we will bring a case along to the meeting where we share and reflect together on what we could have done better. We also have a regular scheduled meeting with the local community pharmacy teams.

 

On joining the practice, I went back to basics and completed the NES GP pharmacist foundation framework in year one. I have recently completed patient feedback and 360-degree feedback from my fellow team members in preparation for hopefully submitting my advanced stage 1 portfolio at Christmas. And you might be wondering why I went back to do foundation 10 years into being a pharmacist. This decision addresses my concern that some pharmacists feel that just because they have experience under their belt as a non-prescribing pharmacist this will transfer into competence as a prescriber.

 

It absolutely does not transfer. Working as a prescribing pharmacist is a different role from the traditional dispensing role and requires support similar to the intensity outlined above to gain the required skills.

 

So how do we make PIP practise safe as we develop many in this role?

 

Working as an independent pharmacist prescriber is a complex activity. I think the first cultural shift for pharmacists is to understand that you cannot take comfort in a standard operating procedure when engaged in prescribing activity. You can have protocols to guide what you are doing but at the end of the day as a PIP you will be exposed to a much more varied and nuanced type of risk. I often finish my clinics these days craving some certainty. As PIPs we often have to manage risk and make decisions based on thorough history taking and clinical assessment. In these instances it is critical to justify and document your thought process.

 

And that leads me to the next culture shock. Over the 8 years I worked in community pharmacy I had 1000’s of consultations of varying depth but I recorded none of them in a structured standardised way. Why? Basically, because there was no requirement to. I had feedback early on from a senior partner at work who questioned me when I said that a patient had exhibited ‘guarding’ when I examined their abdomen. The trouble was that at that point in my training I didn’t fully understand the importance of the language I used when writing in the patient record. In this case I had misinterpreted the word guarding and what I had actually observed during that examination was tenderness. The former could indicate an acute abdomen and therefore potentially that patient would have needed to be admitted. The skill of writing in the record is therefore complex and requires skill and precision to ensure medicolegal rigour. I have no idea how a pharmacist could self-teach this skill but this is what I see happening.

 

Clinical supervision by medical colleagues is critical to support the development of PIPs as they gain confidence. I have had 100’s of hours of supervision and feedback to help me progress to the juncture I find myself at today. This is yet another culture shock and I actually had to get used to others being interested in my development as a pharmacist. The practice I work at are a training practice for GPs so they are used to these processes but nevertheless the culture there is completely impressive and I am absolutely grateful for this. Within the bubble of supervision my GP colleagues manage the overall risk of the multidisciplinary team as we all progress. This allows them to retain control but continues to push us all forward. I would be very sceptical of the overall safety of any PIP who qualifies and then begins prescribing without medical supervision. I think the concept of community pharmacy training practices would be a good way to address this need but again I think we are some way off this.

 

The GPhC state that as a PIP you must work within your competence. My view in this area has hardened as I have gained experience. Whilst I’m not sure that every PIP needs to become an advanced clinical practitioner (ACP) I do feel that as a minimum they should build a portfolio of competence relevant to each area of prescribing practise that they are involved in. I would be nervous and sceptical about any situation that involves self-declaration of competence with no third-party involvement. Competence based portfolios must be signed off and validated by experienced medical prescribers at this stage. I think pharmacists will be capable in due course of doing this but at the moment the vast majority of PIPs are not ready for this level of responsibility.

 

I think PIPs need training on how their risk profile changes over time. We can learn from the aviation industry here. When you qualify you will be unconsciously incompetent in many areas. You are risky at that stage. As you gain confidence you will most likely get a fright or two and subsequently, you will take things slowly and become cautious. Time will pass and the brakes will come off again. At this secondary point approximately 1000 hours into practising as a prescriber I think you will likely become risky again. You need to ensure your indemnity insurance is watertight. Again medical supervision is essential to manage this risk and help you to gain insight into understanding it today and how it might develop over time.

 

I now own a business and therefore make professional decisions regularly about to what degree I engage commercially in the market. Pharmacist prescribing could be seen as getting your hands on the keys to the sweetie jar and you suddenly have the ability to give patients what they want. You are now a clinical decision maker. I have seen some business models where PIPs receive payment only if they prescribe an item. This presents an overt conflict of interest especially if prescribing and dispensing on the same premesis. I think the Scottish Electronic Minor Ailments Service (EMAS) is a much better commercial model to reimburse PIPs for managing patients. EMAS in Scotland is funded by the NHS and provides a payment structure within which the pharmacy owner receives payment based on the number of patients registered on the service in that community pharmacy. The aspect of this commercial structure that I like is that it actually creates an environment within which there is a disincentive to prescribe any medicines but doesn’t penalise if a prescription is required. Once your customers realise that you can prescribe a wide range of medicines, most notably antibiotics, you will be inundated. You need to think professionally how you will manage these expectations given the commercial pressure to make the business viable.

 

All PIPs should be supported to reflect on and audit their own practise. It is essential that this happens to identify PIPs as outliers and identify unusual or potentially risky practise. This concept is standard practise for our medical prescribing colleagues.

 

I was alarmed recently to learn that many PIPs practise in a range of settings without access to the full medical record. My view, based on my experience would be that prescribing without access to the full patient record should be the exception to the rule and not be the norm. There is so much relevant information in the patient record that could have a direct bearing on prescribing decisions. Blood results, previous diagnoses, actions in previous consultations, communication from third parties including consultants and allergies are just a few things that are essential pieces of information to ensure safe prescribing. I would need to be convinced that a PIP working full time without the patient record can do so safely. I would turn this around and ask why would you not want full access?

 

The above points are not exhaustive and there are more aspects to the practise of a PIP that are required to make it safe. I am not a jobsworth in fact I think for a pharmacist I am quite brave in terms of the risk I take on. But you can only demonstrate this courage if you understand the risk you are taking. And yes this is a sweeping statement but I do see a considerable lack of insight by some in our profession in terms of prescribing practise. Most concerningly I see this lack of insight at all levels of our profession including those professing to be our leaders.

 

I have questions around the ability of the GPhC to regulate in this area which is why I welcome the current consultation. I think other representative bodies really need to get ahead of this issue and do what they call ‘horizon scanning’ to support their members to prescribe safely.

 

My final thought on this topic is around what it means to be a pharmacist. I think we need to get back to championing the notion of professionalism. Without professionalism, we are simply painting by numbers. Independent prescribing provides a mechanism for pharmacists to eventually work autonomously and provide excellent care for patients. I actually see it as a lifeline for our profession to survive and thrive into the future and I would hope in years to come pharmacists will qualify as prescribers. I am completely optimistic about the future of our profession and I hope my concerns don’t put pharmacists off completing the qualification.

 

One of the highlights of my professional life was when I signed my first prescription. I got a glimpse of profound professional autonomy and I think it is this professional autonomy that we should aspire to.

 

If we choose not to take this step we will forever be followers not leaders in patient care.

 

Prescribing in community pharmacy: The next big thing or a risky business?

Johnathan Laird MRPharmS(IP)

 

Make no mistake pharmacist independent prescribing can easily become a very risky and potentially dangerous activity if the level of competence of the prescriber is not sufficient.

 

With so much political pressure to churn out endless independent pharmacist prescribers (PIPs) I thought it might be a useful juncture at which to share my thoughts on how my opinions have formed over the last four years after qualifying as an independent prescriber.

 

As with most topics, I tend to take the middle road. I think pharmacist prescribing is essential to secure the future purpose of our profession. I am however concerned at how rapidly it is expanding and also the lack of regulation around various aspects of being a pharmacist prescriber.

 

I qualified as a PIP back in June 2015. I have been actively prescribing since then. Before I begin my narrative, I thought it might be useful to explain for the uninitiated what a PIP actually is and what they are legally allowed to do.

 

I think it would surprise the vast majority of the general public if they knew that, with a few exceptions, PIPs can write prescriptions for almost every licensed and unlicensed medicine. PIPs must complete the GPhC accredited training course delivered by one of the accredited learning provider Universities around the UK. The GPhC has stated that when prescribing pharmacists must do so within their own sphere of competence.

 

The beginning

 

I completed the course delivered by the Robert Gordon University in Aberdeen. At that time the course basically involved a period of learning in practice, a small amount of face to face training, an assessed OSCE and a number of written assessments that had to be submitted.

 

I completed the required elements, my designated medical prescriber signed off my portfolio and off I went to apply for annotation on the GPhC register.

 

And that was that.

 

Into the sunset, I marched to begin my independent prescribing odyssey. I was working for a large multiple back then. There was no commercial interest for them in me providing independent prescriber led services in community pharmacy. Looking back, to be honest on both the commercial and the risk front they were absolutely spot on. There were some local NHS funds that we managed to access at that time. My employer was to be paid £150 for a three-hour independent prescribing session facilitated by me. My wage was unaltered.

 

I didn’t know it at the time but this was the first time I fell foul of being unconsciously incompetent. I was delighted to get a shot at my dream of beginning to manage patients and get going with my pristine prescription pad.

 

How wrong I was.

 

This level of investment is, to be honest laughable. If you attempt to quantify the extra risk to the individual pharmacist, the increased indemnity insurance premiums, the required competence based CPD, the medical supervision arrangements that should be in place you will lose money. In my view that hourly rate would need to be quadrupled at least to provide proper investment to nurture community pharmacist independent prescribing initiatives. My view would be that even at a much higher price if run well the service would pay for itself. That said, results may not be immediate which is never what ambitious political types at various levels of the system want to hear.

 

But it wasn’t about money for me. So I kept going.

 

My story is reasonably well known but to summarise, in partnership with my local GP colleagues, I began to identify high-risk respiratory patients and begin the process of bringing these patients back into the system. It is well known that people with asthma often don’t attend for annual review and in the meantime, can struggle to manage their condition themselves. Anyway, this was a success and I demonstrated that I could use the community pharmacy platform to reach people with asthma who were disengaged. I began to manage these patients. I even audited my practise and looked specifically at salbutamol use in this cohort. Interestingly the graph that I produced looked exactly like the one published in NRAD. The difference being all my patients were very much alive. It was food for thought and at that time these early audits gave me great motivation to continue. I did this early prescribing activity collaboratively with my colleagues at the surgery but I largely made it up as I went along treading as carefully as I could.

 

I may talk a good game on here but when it comes to the crunch I’m as cautious a pharmacist as the next person.

 

From a prescribing perspective, I began by using my qualification to address many of those annoying things that happen in community pharmacy. For example, I was prescribing alternative medications and informing my GP colleagues back then years before any mention of shortage protocols or the like.

 

I would always prescribe within my competence so that was fine, wasn’t it?

 

Of course, prescribing within your competence is absolutely essential but learning as I did basically unsupervised in those early days looking back was not a clever idea. These days I feel looking back that this was not the best approach and I wouldn’t advocate it now. Beginning to prescribe should be done under medical supervision in my view. I think there are very few pharmacists capable of supervising prescribers at this stage. Now the items I was prescribing were low-risk creams or swapping tablets for capsules but the fact remains if as a profession we intend to scale activity in this area, which our political masters seem intent on then there should be a standardised approach baked in from the start.

 

I would summarise my early community pharmacy prescribing days as largely consciously incompetent. My caution won the day and I would never overstep the mark into an area where I had very little competence. The result of this was a self-induced stalling of my progress. I spent most of my time prescribing inhaler spacers (absolutely nothing wrong with this btw) which was a useful activity but I wanted my impact to be broader than this. There were, and are largely now, no structures for training PIPs in the community. This is changing in Scotland but even those in charge of these endeavours would recognise that it is very early days and also I suspect that once they realise the cost of mitigating associated risk the cries for increased funding will appear and grow louder.

 

This stalling of progress led me to take the leap that so many others have made to the promised land of general practice. I have not really written about my experience of working in general practice largely because until now (2 years in) I had my head down finding my feet in this devilishly complex yet interesting role.

 

Do I love it? Hell yes but I still want to own a community pharmacy someday. It’s where I feel most professionally at home.

 

I have developed professionally more in the last two years than I have since I qualified, except perhaps in the first couple of years post qualification when the learning curve is steep.

 

My final thought on this topic is around what it means to be a pharmacist. I think we need to get back to championing the notion of professionalism. Without professionalism, we are simply painting by numbers. Independent prescribing provides a mechanism for pharmacists to eventually work autonomously and provide excellent care for patients. I actually see it as a lifeline for our profession to survive and thrive into the future and I would hope in years to come pharmacists will qualify as prescribers. I am completely optimistic about the future of our profession and I hope my concerns don’t put pharmacists off completing the qualification.

 

One of the highlights of my professional life was when I signed my first prescription. I got a glimpse of profound professional autonomy and I think it is this professional autonomy that we should aspire to.

 

If we choose not to take this step we will forever be followers not leaders in patient care.

 

In my next article in this mini-series, I will reflect on my experience working in general practice so far.

 

Community pharmacy prescribing in Scotland

Sam Falconer is a community pharmacist. His current role is that of pharmacy manager at Kilwinning’s Townhead Pharmacy.

 

Sam and his team are carving out a reputation for innovation and excellence in the delivery of pharmaceutical care a the heart of their community. Sam is an independent prescriber and he has been using this qualification to deliver a common clinical conditions service.

 

This service involves him assessing and prescribing for conditions like tonsilitis, ear problems, chest complaints and other ailments not covered by the Scottish Minor Ailment Service. He is already making an impact locally and the people that use his services are extremely satisfied with the work he does for them.

 

He was good enough to join me on the podcast to talk through how he has achieved this but also some of the challenges along the way.

 

If you want to understand how to run a well thought through independent prescriber led community pharmacy common clinical conditions service then this podcast is for you.

 

 

If you prefer to never miss an episode you can subscribe on your preferred podcast platform. Just click on the links below to get going.

 

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Three further batches losartan recalled from pharmacies

 

The MHRA has recalled three batches of Losartan tablets due to contamination with the nitrosamine N-nitroso-N-methylamino butyric acid.

 

As a precautionary measure to protect public health, the Medicines and Healthcare products Regulatory Agency (MHRA) today recalled three batches of Losartan tablets due to contamination with the nitrosamine N-nitroso-N-methylamino butyric acid (NMBA). The affected batches can be viewed here.

 

The recall is taking place as part of the continued investigation into potential nitrosamine contamination of sartan containing medicines, a class of medicine to treat blood pressure and heart attacks and heart failures.

 

Currently, there is no evidence that nitrosamine impurities can cause harm and patients are being advised to continue taking their medication.

 

The investigation into possible contamination of sartan medicines began in 2018, after the nitrosamine N-nitrosodimethylamine (NDMA), was identified in valsartan manufactured at a facility based in China.

 

Last year, the MHRA recalled batches of valsartan containing tablets to pharmacy level in July and November due to possible NDMA and N-nitrosodiethylamine (NDEA) contamination.

 

In January and February 2019 the MHRA recalled batches of irbesartan containing tablets after testing revealed possible contamination with NDEA.

 

The MHRA continues to monitor the situation in the UK and are comprehensively investigating the issue alongside the European Medicines Agency (EMA) and the European Directorate for the Quality of Medicines (EDQM).

 

Bernadette Sinclair-Jenkins, MHRA’s Manager, Regulatory Assessment Unit of the Inspection, Enforcement and Standards Division, commented:

 

“Our priority as regulator is to make sure the medicines you and your family take are effective and acceptably safe. This recall shows we are continuing to investigate potential contamination of sartan containing medicines. There is no evidence at present that medicines containing NDMA, NDEA or NMBA have caused any harm to patients and this recall is a precautionary measure. Because of the risk associated with suddenly stopping high blood pressure medication, continue to take your medicines as prescribed by your doctor.”