by Rob Davies MRPharmS MFRPSII, a pharmacist independent prescriber in the BCUHB managed practice at Healthy Prestatyn / Rhuddlan Iach, and Member of the Welsh Pharmacy Board
I work in the BCUHB-run primary care service of ‘Healthy Prestatyn / Rhuddlan Iach’, an innovative multi-disciplinary primary care service. The medicines team includes five pharmacists, pharmacy technicians and prescription clerks. Each pharmacist is in a multi-disciplinary team (MDT) caring for over 4,000 patients with GPs, advanced nurse practitioners, practice nurses, an occupational therapist, a physiotherapist and a key team coordinator.
My role includes independent prescribing, patient telephone consultations / medications reviews, liaison with community and hospital pharmacists about our mutual patients, and education of pre-registration pharmacists and medical students, and others all within the context of the MDT.
As an independent pharmacist prescriber, I run twice-weekly face-to-face clinics. My prescribing area and competence has developed from initially hypertension / cholesterol / CVD risk to currently include medication and polypharmacy review, mild-to-moderate pain relief and benzodiazepine reduction. This patient contact is valuable to the practice by providing alternative clinicians for patients, helps contextualise the reviews we do at other times and, as many patients have told me, is also of value to them. One patient, who was initially sceptical of the pharmacist’s role, subsequently had a thorough medication review (discussion of cardiovascular risk & Q-RISK, benefits and risks of potent dyspepsia medication). They later wrote to thank the medical director for the MDT approach and has contributed to my portfolio. Other patients have agreed to have their cases presented for shared learning as MDT working.
There is no doubt that this type of pharmacist working in a MDT can decrease GP workload, but the role is so much more that that as the following examples illustrate:
- Elderly patient who had become frail in recent months requested a review to understand her medicines and help with reduction in diazepam use; she attended clinic with her grand-daughter. She had already made great progress reducing diazepam from 5 mg daily a year previously to 2 mg daily. We agreed a regimen to 1 mg daily over 6 months and I explained reason for and ordered blood monitoring tests for her ongoing treatments (U&E, TFT, LFT), and referred her to the occupational therapist (OT) for some help with ‘coping skills’.
- A patient who acknowledged he was very frustrated with NHS services and had previously been on escalating doses of opioids for chronic pain has been re-engaged with services through an MDT (pharmacist, OT, GP, pain clinic) approach, is on stable treatment and looking to a future with less medication
- A 74-year-old patient with acute back pain having tried his wife’s tramadol requested a supply for himself. At review, we completed the NICE/Keele STarT back pain assessment tool; he was at significant risk of his pain becoming chronic. By careful discussion, an acute prescription for co-codamol 30/500 and referral to our OT-run ‘Back Skills’ course, he is now more confident in pacing activities and managing his own acute back problems, without strong opioids.
- A young adult patient was referred following examination by his optometrist was found to have normal blood pressure; later I had a brief discussion with his GP and then reassured patient of his concerns excluding a serious diagnosis.
- Medication review and BP check with patient noted high over licence use of paracetamol and co-codamol 30/500 for daily headaches, patient agreed to decrease to licensed dose; BP may have been high as ‘feeling stressed’. I agreed to refer to OT for life-coping skills and to investigate the possibility of analgesic-associated headache.
- Patient had not realised the importance of the regular safety blood tests with some medication eg U&Es for monitoring renal function and electrolyte balance whilst on ACE inhibitors and diuretics. Following explanation agreed to attend for blood tests.
- Regular patients for review of CVD risk are offered appropriate lifestyle advice, smoking cessation, dietary advice and weight management.
I have found that as patients make return visits, the incidence of ‘white coat hypertension’ tends to decrease.
Telephone consultations with patients / medication reviews
Telephone consultations with patients / medication reviews vary from the brief to complex:
- A 15-minute discussion with housebound patient advising on analgesic doses.
- An 82-year old with shingles 6 weeks previously, requested the vaccine his wife had recently received. I contacted the immunisation co-ordinator who advised it inappropriate.
- Patient requesting further acute antidepressant. Own GP unavailable but I consulted with another and then prescribed
- Telephone consultation with an elderly patient with post-shingles pain, I discussed with GP and then I prescribed analgesic for neuropathic pain
- Patient recently discharged from hospital post surgery still in pain. I discussed with GP and prescribed short-course weak opioid pending forthcoming hospital review. She also requested diazepam for chronic back pain. I advised that this is not first-choice treatment, and for routine GP discussion.
- Telephone review with a patient concerned HRT might be causing worsening of her migraine. We discussed the possibility of a patch
- Advising patients of need for regular monitoring of complex therapy.
Liaison with community and hospital pharmacists
Almost daily I have telephone conversations with community pharmacy or hospital colleagues about our mutual patients. For example:
- A community pharmacist colleague discussed three patients she intended starting on nicotine-replacement therapy. We agreed to monitor for potential medication over dosage due to less liver enzyme induction once patients cease smoking. This served as useful CPD for my GP colleague who was unaware of this interaction.
- Community pharmacist told me of shortage of losartan liquid for a 5-year-old. Following liaison with hospital paediatric pharmacist and as the patient’s mother stated her son could take a small tablet, I prescribed a tablet which could be halved.
We also frequently liaise on appropriate patient monitoring, compliance and safety issues following medicines usage reviews, and consideration of patients for batch prescription / repeat dispensing.
Within the pracice, Our MDT meets regularly for a team perspective regarding complex cases and this has led to joint patient consultations between pharmacist and GP, pharmacist and OT, pharmacist and community psychiatric nurse. Patients are regularly referred between colleagues (GPs, nurses, pharmacist, OT, physiotherapists, audiologist) as we develop MDT working.
Education and training
Having been a NICE Therapeutics Associate, I have a long-term interest in implementation of evidence-based practice, education, and training. Consequently, it is enjoyable having different colleagues (such as medical students, pharmacists on advanced courses including prescribing, and physician associates) for work shadow or discussions. We discuss consultation styles, shared decision making, explaining risk to patients, and using natural frequencies rather than percentage. In promoting health literacy, we refer patients to reliable information such as NHS Choices website. I also am the primary care mentor for the UK’s first integrated (cross hospital, community and primary care) pre-registration pharmacy course, now on the second year. A recent discussion with the pre-registration pharmacy graduate concerned her cross-sector audit improvement project involving polypharmacy review.
Future evolution of the role
Though our service is still a work in progress, we are trying to make sure the whole medicines team work at the top of their competency. The pharmacy team contributions are already recognised as an integral part of care by patients and colleagues alike. Since I started in primary care over 25 years ago, there have been so many welcome developments in medicines management with practice pharmacists and technicians becoming routine rather than the exception, independent prescribers and even a few pharmacist partners. In my view, there should be no limit to pharmacy’s contribution to patient care in the primary care setting, with the development of integrated pre-registration training, diploma pharmacists in primary care, an emphasis on lifelong learning and development of advanced practitioner roles. Why not consultant pharmacists in primary care?