Why pharmacists should manage repeat prescriptions

The current system for repeat prescriptions for patients with stable conditions requires them to return to the GP every 6-12 months even if nothing has changed.  Allowing community pharmacists to manage repeat prescribing “would take a huge amount of workload off general practice and enable them to spend their time doing the things that they really are experts at doing”, he says. Community pharmacists, who are experts at managing medicines and medicines’ optimisation, could monitor patients effectively and manage medicines for those with stable conditions. Much of this could be done under agreed protocols and that could bridge the gap until all community pharmacists are prescribers, he argues.

Getting Serious Shortage Protocols (SSPs) to work

Medicines’ shortages are depressingly frequent and, despite the existence of Serious Shortage Protocols (SSPs) to ensure that alternative medicines are available when shortages occur, numerous problems have arisen. The SSP scheme is not as flexible and responsive as it needs to be and sometimes the way in which the schemes operate in practice simply leads to new shortages and delays in treatment. Pharmacists are clinicians who care about patients and need to be trusted to provide the appropriate alternatives when a specific product is unavailable, says Professor Soni. Patients do not want to be travelling back and forth between health care professionals trying to find a solution, “they want the solution in one easy place so let’s find ways that the patient has that access at the point they want it, in the way they want it”, he says.

Reducing harm from medicines and improving the patient experience

About eight per cent of hospital admission are due to medicines-related harm. This could be reduced by improving prescribing and pharmacy-led medicines optimisation initiatives. Such measure should release capacity for patient care. Ideally pharmacy services should be built in when new initiatives are planned. Although this did not happen for the covid vaccination campaign it quickly became apparent that without input from community pharmacy there would be insufficient capacity. Now, the majority of vaccine provision for covid is now delivered through community pharmacy, explains Professor Soni.

Integrating community pharmacy and primary care

The National Association of Primary Care (NAPC) is an organisation that is focused on the delivery of care outside hospital. As such it embraces all branches of health and social care, including the voluntary sector. It’s guiding principle is “about enabling people at local level to build things from the ground up”, says Professor Soni.

His closing message to the Secretary of State for Health and Social Care is, “All pharmacists have a role to play in supporting improving care. …… We want to be part of your solution – we can be part of your solution – but you have to include us for that to happen.”

Pharmacists have a role to play in supporting improving care. If you really want us to help, we can – just come and ask us, let us. We want to be part of your solution – we can be part of your solution – but you have to include us for that to happen.”

Read and watch the full series on our website or on YouTube.

The National Association of Primary Care (NAPC) is an organisation that is focused on the delivery of care outside hospital. “Their perception and the description of primary care is basically everything outside hospital, whether that’s social care whether that’s the voluntary sector, …. community services, pharmacy, dentistry optometry, general practice – it’s all of it – and the role of the NAPC has been to be about how .. we improve care at local level”, says Professor Soni.

NAPC created the concept of ‘Primary Care Home’ which was about local working based around populations of between 50 and 100,000, so that there was a group of people who were responsible for the care of the population within that area.  NHS England adopted the idea and developed Primary Care Networks (PCNs). Unfortunately this lost sight of the original objective of Primary Care Home that was “about enabling people at local level to build things from the ground up, in a way, and to think about how and what they need to do”, explains Professor Soni.

One of his objectives as president is to raise the profile of pharmacy but also to “be a voice on behalf of the broader perception of primary care”.

This, he says, is about “driving home this difference between primary care and general practice and the fact [that] the two terms are not interchangeable …. you might talk about primary medical care and primary pharmaceutical care and primary dental care and primary optometry care but altogether they provide primary care. And that includes the voluntary sector, community sector [and] all of the other providers that can help support patients and the public to improve their care. If we get this right, the principle has to be [to] support neighbourhoods to build more resilience within their populations which enables the clinicians, whoever they are – the professionals, to be there to provide the care that’s needed at a time when it is needed.

Key messages

Professor Soni summarises his key messages:

Pharmacists should recognise how skilled and talented they are and recognise that they can use those skills and talents to provide better care and support better care for the public they are there to support.

Integrated Care Services (and pharmacists within the ICS) should think about how they can integrate with others and work collaboratively with other professions to provide the best care for people and keep focused on patient-centred care. “If you look at a lot of the work that happens it still tends to be driven by what the professionals, the clinicians, whoever they are, can do rather than what the public needs.  What we have to do is move much closer to being able to deliver what the public need and by supporting that we’re then able to deliver better outcomes for everybody that we serve”, he says.

Finally, Professor Soni’s message to the Secretary of State is: “We can help; there are things that we can do. Medicines are the single biggest intervention of the NHS   so actually pharmacists are a critical part of it – not just pharmacists at hospital level or pharmacists in general practice or pharmacists in ICSs or community pharmacists – all pharmacists have a role to play in supporting improving care. If you really want us to help, we can – just come and ask us, let us. We want to be part of your solution – we can be part of your solution – but you have to include us for that to happen.”

About Ashok Soni OBE

Ashok Soni OBE is president of the National Association of Primary Care (NAPC) and is the first pharmacist to hold this position. As a community pharmacist and owner of three pharmacies, much of his time over the past two to three years has been devoted to vaccinations.  Having “some incredibly talented staff” has enabled him to take on a number of other roles: He is a non-executive director at Oxford University Hospitals and  a non-executive director at Sussex Integrated Care Systems (ICS), known as NHS Sussex, where he chairs the Workforce and Remuneration body.

Read and watch the full series on our website or on YouTube.

The UK, through the then Secretary of State for Health, Andrew Lansley, signed up to the WHO global initiative aiming to reduce the level of severe, avoidable harm related to medications by 50% over the next five years. However, the way that it was tackled focused largely on improving safe prescribing. This approach did not enable pharmacists to be as effective as they could be, says Professor Soni. Given that approximately eight per cent of all hospital admissions are medicines-related, a stronger focus on medicines optimisation would have helped, he explains.  Optimising the use of medicines is likely to reduce the numbers of patients admitted to hospital for medicines-related causes and that releases capacity for patient care, he adds.

One problem that commonly occurs when patient pathways are being designed is that the way medicines and pharmacy services tend to be an afterthought rather than being a fundamental part of the pathway. “It’s not deliberate, in the sense that the people that are there ignore it, but you don’t know what you don’t know, and if you haven’t got a voice there that’s raising it you don’t hear it – and therefore it   becomes a gap”, he says

A good example of this was the planning for the coronavirus pandemic.

“When planning historically has been done for pandemics, or for any type of major event like that, they never included pharmacy. [It] was never seen as part of the solution and yet without pharmacy in its broadest context the entire vaccination program would have fallen over”, says Professor Soni.  Pharmacists and pharmacy services were needed to manage storage and logistics for vaccines that had to be kept at very low temperatures. “Then you had the whole issue about who was providing it – who was delivering it. Well actually, if you didn’t have the pharmacists on site, they didn’t know how to make it up, even in some of the in some of the central sites that they used, so, again a pharmacist was essential. Community pharmacy’s being part of the provision was a bit of an afterthought. We weren’t included at the very beginning we were included quite quickly because there was a realisation there wasn’t enough capacity – but it was still an afterthought. And yet now, the majority of vaccine provision for covid is now provided through community pharmacy. That is the biggest site, particularly in London, compared to any other provider – so you can see how it’s become more important”, he explains.

Professor Soni notes that community pharmacy has progressively taken on the bulk of flu vaccination as numbers increase year on year. Many GPs have told him that they are seeing fewer patients for flu vaccination than they did in the past.

“That’s where patient choice becomes a really important part of the jigsaw. So, it’s really important you include all of the players who are involved as part of what you’re trying to do. You need to involve the people on the ground who are doing some of this because actually innovation comes from the ground up – it doesn’t tend to come from people who do the buying”, he concludes.

About Ashok Soni OBE

Ashok Soni OBE is president of the National Association of Primary Care (NAPC) and is the first pharmacist to hold this position. As a community pharmacist and owner of three pharmacies, much of his time over the past two to three years has been devoted to vaccinations.  Having “some incredibly talented staff” has enabled him to take on a number of other roles: He is a non-executive director at Oxford University Hospitals and  a non-executive director at Sussex Integrated Care Systems (ICS), known as NHS Sussex, where he chairs the Workforce and Remuneration body.

Read and watch the full series on our website or on YouTube.

Serious Shortage Protocols (SSPs) are only put in place after a shortage has been recognised and referred to the Secretary of State so “it’s not flexible or reactive as quickly as it could be …and we could do that more effectively”, says Professor Soni.

Currently a SSP in place for antibiotics for treatment of Strep A. Previously, there was a shortage of HRT and the system was slow to respond, creating difficulties for pharmacists, patients and doctors, he recalls. One of the problems with the current process is that if the SSP provides only one alternative product, there is a danger that a shortage of the alternative products also quickly develops. Community pharmacists are then obliged to send patients back to the GP for a different prescription, with all the consequent delays and frustration that that entails. Local protocols listing the appropriate alternative treatments that could be dispensed would be an efficient way to address this problem, he suggests. “The challenge again is, in a way, what you’re saying is the pharmacist takes responsibility for the decision- making, so it’s a bit of a stretch on the repeat prescribing. ….. to be able to say, ‘Well, I can’t get product X but product Y is equivalent and therefore I can use that to support ….. the care of the patient rather than having to bounce [them] backwards and forwards to be treated”, he adds.

The current SSP for phenoxymethyl penicillin (penicillin V) has been written to provide a list of alternatives to be supplied in descending order. However, in order for the pharmacist to be able to dispense an alternative antibiotic in accordance with the SSP, the prescriber has to write a prescription for the (unobtainable) phenoxymethyl penicillin. Professor Soni confirms, “you’re asking [them] to prescribe the wrong thing to get the right thing”.  Worried patients might, in the meantime, contact their GPs to make sure that the alternative is satisfactory. If the GPs then decide to prescribe one of the alternative products to avoid such problems, there could be further difficulties because the SSP cannot then be used to supply an alternative in the event of a shortage.

Although the phenoxymethyl penicillin SSP makes sense from an administrative viewpoint it does not reflect what going on in practice. Professor Soni says, “There’s an element of this which is about lack of trust in us as pharmacists to make the right decisions and that’s part of the problem …….. Well, you’ve got to start to trust us. We’re clinicians, we care about patients. It’s not about the money, it’s about the quality of care that we provide; the money is a consequence and in a way it’s why I go back to [saying] help us to support the right decisions and it’s for other people to work out how the money flows”.

Patient-centred care

Patient choice is critical when designing new systems. “I think it’s really important that one of the things we bear in mind with all of this is about patient choice and what the patients and public would like to do”, says Professor Soni.  Patients do not want to be travelling back and forth between health care professionals trying to find a solution, “they want the solution in one easy place so let’s find ways that the patient has that access at the point they want it, in the way they want it”, he says. This involves supporting all staff involved in patient care to deliver high-quality care. In addition, “We need to … make sure that we do genuinely build an integrated digital solution – and we have to see that as part of what we do. It doesn’t mean that I have to be able to write to the same records to as someone else – I may be able to write independently but it then populates the same record”, he explains. Innovative approaches to digital solutions could enable the use of up-to-date technology to build the best digital solutions that we can, he says.

About Ashok Soni OBE

Ashok Soni OBE is president of the National Association of Primary Care (NAPC) and is the first pharmacist to hold this position. As a community pharmacist and owner of three pharmacies, much of his time over the past two to three years has been devoted to vaccinations.  Having “some incredibly talented staff” has enabled him to take on a number of other roles: He is a non-executive director at Oxford University Hospitals and  a non-executive director at Sussex Integrated Care Systems (ICS), known as NHS Sussex, where he chairs the Workforce and Remuneration body.

Read and watch the full series on our website or on YouTube.

Professor Soni’s first recommendation is to allow community pharmacists to take on the management of repeat prescriptions for long-term conditions. GP colleagues have told him that the “repeat prescription process is quite laborious from their point of view”. Community pharmacists, who are experts at managing medicines and medicines’ optimisation, could monitor patients effectively and manage medicines for those with stable conditions by working within agreed protocols, he says. If the situation changed then they could be referred to their doctor or to a specialist pharmacist, as appropriate. Allowing community pharmacists to manage repeat prescribing in this way “would take a huge amount of workload off general practice and enable them to spend their time doing the things that they really are experts at doing”, he says.

Initially, it would not be necessary for all community pharmacist to be prescribers, although that is the ideal position, Professor Soni concedes. “Over the course of the next two to three years we’re going to see that happen anyway, and actually, by 2026, all pharmacists coming out of university will be prescribers. And, hopefully, the vast majority of pharmacists that are already working out in communities will have had the opportunity to train as prescribers”, he says.

One of the problems with the current repeat dispensing system is that after 6 -12 months the prescription effectively expires and patient is obliged to return to the GP to renew the prescription, even if their condition is stable. This particular workload could be avoided altogether using a pharmacy-based system. The pharmacist would be able to identify patients whose needs had changed and, with appropriate IT, communicate with the GP or nurse quickly and efficiently so that patients “go [to the GP] when they need to be seen rather than just because the system says it’s time”, he says.

It would, of course, be necessary to introduce a suitable system for payment for these services. This could be on fee-for-service (activity) basis or could be payment for a patient’s care for a period of time.

Professor Soni argues: “My purpose is to come up with the proposal about what we can do. It’s for others then to work out …. what’s the best way to pay for it.  There are different ways to make that work ….. and I think we can. There’s no reason why you can’t find the resource to do that because if I’m releasing capacity from general practice, and that means that maybe some patients aren’t going into hospitals that currently are, because they’re better managed by the GP as well as by us, that’s going to save money at some point in the system and therefore that money is just being redistributed”.

About Ashok Soni OBE

Ashok Soni OBE is president of the National Association of Primary Care (NAPC) and is the first pharmacist to hold this position. As a community pharmacist and owner of three pharmacies, much of his time over the past two to three years has been devoted to vaccinations.  Having “some incredibly talented staff” has enabled him to take on a number of other roles: He is a non-executive director at Oxford University Hospitals and  a non-executive director at Sussex Integrated Care Systems (ICS), known as NHS Sussex, where he chairs the Workforce and Remuneration body.

Read and watch the full series on our website or on YouTube.