Sam Akram's article describes the changing role of pharmacists, the role of clinical pharmacists, and how nurses and pharmacists can work together to best manage patients in primary care.
Read this article to learn more about:
- how the role of pharmacists has changed
- the role played by clinical pharmacists
- how nurses and pharmacists can work together to best manage patients.
As the pressure on NHS services continues to grow it is important that we consider how healthcare professionals' expertise is used to help patients and make improvements where possible.1 Nurses and pharmacists have complementary skills and can work together in a number of different ways to improve the way patients use their medicines and the resulting outcomes.1 The Royal College of Nursing and the Royal Pharmaceutical Society held its second joint summit in December 2015 to showcase how nurses and pharmacists are working together in different ways to deliver care to patients and to inspire nurses and pharmacists to make local changes in the way they work together.1
A literature review was performed to determine what evidence there is to support task substitution between GPs, pharmacists, and practice nurses in the care of elderly people living in the community.2 It was found that when nurses or pharmacists performed certain tasks normally performed by GPs, including health promotion and disease management in accordance with guidelines and protocols, process of care and patient outcomes (e.g. disease control) were improved.2 The study also concluded that when task substitution is implemented the healthcare professionals' roles must be complimentary to prevent any duplication of effort.2 It is likely that these findings for the care of elderly people will also apply to the wider patient population.
What is so clinical about clinical pharmacists?
Pharmacists have been working in GP surgeries since the 1990s. More recently clinical pharmacists have been introduced. The role of a clinical pharmacist in general practice is more patient centered than that of a pharmacist. The General Practice Forward View developed by NHS England and Health Education England, in discussion with the Royal College of General Practitioners and other GP representatives, is backed by a multi-billion pound investment and has been introduced to stabilise and transform general practice.3 As part of this, £31 million has been invested to pilot 470 clinical pharmacists in over 700 practices; a new central investment of £112 million will extend the programme by a pharmacist per 30,000 population for all practices not in the pilot: it is expected there will be a further 1500 pharmacists in general practice by 2020.4
Pharmacist independent prescribers are able to prescribe anything in the British National Formulary as long at is within their competence to do so, just the same as nurse and medical practitioners. To become an independent prescriber, pharmacists must complete a General Pharmaceutical Council-accredited programme. Pharmacist-specific courses are also being offered teaching competency in clinical assessment skills. It is becoming more common to see pharmacists using stethoscopes or other common medical instruments, and performing common medical examinations essential for minor illness. Given the current demands and pressure on general practice, this upskill is valuable in supporting nurses and nurse practitioners to perform patient triage.
There is huge scope for pharmacists and nurses to work collaboratively in long-term condition areas. Asthma, diabetes, and chronic obstructive pulmonary disease reviews and hypertension caseloads can be shared with general practice pharmacist practitioners allowing patients improved access for their reviews and assisting nurses with their workload.
Box 1: Pharmacist and nurse practitioners working collaboratively in general practice
- Anticoagulant clinic—initiation and monitoring of anticoagulants including prescribing where possible
- Asthma shared caseload clinic—asthma reviews with step up and step down of medication
- COPD shared caseload clinic—spirometry testing as well as performing COPD reviews with step up and step down of medication
- Contraception clinic—initial prescribing of contraception and annual reviews
- Dementia review—routine review of patients with dementia as well dementia screening and optimisation of pharmacotherapy following specialist review
- Diabetes shared caseload clinic—diabetic reviews including foot examination and optimisation of oral treatments; where suitably trained, initiation of insulin
- Epilepsy review—routine reviews of patients with epilepsy
- Heart failure clinics—optimisation of heart failure medication and other medication that may need de-prescribing following heart-failure diagnosis
- Hypertension shared caseload clinic—hypertension diagnosis and management including ambulatory blood pressure monitoring
- Medication review clinic—review of patient medication needs
- Triage and minor illness clinic—triaging patients where necessary as well as dealing with walk-in patients
- Vitamin D treatment clinic—treatment and/or advice for patients with vitamin D deficiency
- Walk-in medication open clinic—dealing with urgent script requests and prescriptions that need amending as well as outpatient medication request letters.
COPD=chronic obstructive pulmonary disease.
Consultation models, including Neighbour's, Pendleton's, and Cambridge-Calgary models, used in general practice have also been adapted by pharmacist and nurse practitioners so they can consult effectively.5,6 Telephone consultations can also be performed by pharmacist practitioners working in collaboration with nurses leading to greater patient contact: this approach can be taken in a GP setting and out of hours.
Telephone medication reviews as well as domiciliary medication reviews can also be performed by general practice pharmacist practitioners.
Breaking inter-professional barriers
Pharmacists have traditionally been viewed as being involved in the supply of medication. Similar to the advent of the nurse practitioner role, the scope of work performed by pharmacists has grown. When working together in a multidisciplinary team, such as a GP surgery, good communication is essential to collaborative working. Attendance at multidisciplinary team meetings, where everyone has the opportunity to learn about the roles played by others, helps to strengthen working relationships and outcomes. Simply trying to delegate caseloads without clear understanding of the other team members’ capabilities or experience will lead to poor outcomes and loss of trust.
Pharmacists are becoming inbuilt members of the GP practice team—effective multidisciplinary team working will result in benefits for everyone but particularly for patients.
- Royal College Nursing and Royal Pharmaceutical Society. Nurses, pharmacists and patient pathways; working together across primary and community care. Available at: www.rpharms.com/support-resources-a-z/nurses--pharmacists-and-patient-pathways--working-together-across-primary-and-community-care.pdf
- Dennis S, May J, Perkins D et al. What evidence is there to support skill mix changes between GPs, pharmacists and practice nurses in the care of elderly people living in the community? Australia and New Zealand Health Policy 2009; 6 (23).
- NHS England. General practice forward view. Available at: www.england.nhs.uk/ourwork/gpfv/ (accessed 19 August 2016).
- NHS England. General practice forward view April 2016. Available at: www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf
- Centre for Pharmacy Postgraduate Education. Consultation skills for pharmacy practice: taking a patient-centred approach. Available at: www.consultationskillsforpharmacy.com/docs/docb.pdf
- Smith S. Nurse practitioner consultations:communicating with style and expertise. Primary Health Care 2004; 14 (10): 37–41. G