Essentially there is no difference between being a GP practice pharmacist and a primary care network pharmacist

When it comes to determining what kind of pharmacy input a PCN or a GP practice needs, Mr Williams says that the wider picture needs to be considered. “It’s a very attractive proposition to come and work in primary care, whether you’re a pharmacy technician or a clinical pharmacist” but “the rate-limiting step is the workforce in the area – so what is happening is [that] we are at risk of sucking people out of secondary care and community pharmacy”

“If we just suck people out from one area, that’s going to destabilize the whole   system” and this has been well-understood by Poole Bay and Bournemouth PCN.   “We have people who are who are employed by the community health trust who might do half their time for us but half their time working for the community health   trust. We have a pharmacist who’s about to start who’s going to work partly in a   community pharmacy and partly for us”, says Mr Williams.  In this way it is possible to have a sustainable approach within the integrated care system and to provide job enrichment for the pharmacy professionals involved. He also stresses that it is important to have staff who are not only clinically skilled but also able to manage people and work well in the primary team.  “I think that is the key – not [just] numbers of people in the PCN but the right people in a PCN”, he says.

Mr Williams says that he has benefited from a great deal of training in the NHS and 30 years of “doing it and failing and realising that you need to do it like this….”.  Looking to the future he would like to share his experience and insights and help other practices and PCNs develop their services.

“We all know that [drug therapy] is still the number one intervention used in healthcare. There are huge potential problems ahead in relation to older people getting more and more medicines [for] more and more conditions and we need to manage that. So, pharmacy professionals working in primary care are an absolute necessity, they’re not a luxury, they’re a necessity. You know the optimal use of   medicines is important for [everyone].  …. If we just keep adding medicines and never subtracting, we multiply the problems – that is what I’m trying to sort”, concludes Mr Williams.

Steve Williams MPhil, BPharm Hons, Clin Dip Pharm, Pharmacist Independent Prescriber, MRPharmS is a Senior Clinical Pharmacist Poole Bay & Bournemouth Primary Care Network. He is also the Founder and Director of One Less Pill Medicines Optimisation Consultancy. You can keep up to date with Steve Williams on Twitter.

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

“It was incredibly rewarding but it was a lot of work, but I’m not shy of doing hard work because I felt that [this study] was really important”, says Mr Williams.

The study was run by Professor James McElnay at the University of Belfast and much of the work was undertaken by a PhD student called Nadia Syafhan, Mr Williams recalls. The GP practice in which he works was one of the eight (two in each of four regions of the UK) that took part. The plan was to recruit 800 patients but, in the event, about 350 were included in the study, randomised on to two groups. In the first instance, adult patients were recruited who were taking six or more oral or inhaled regular medicines and who had also had an unplanned hospital admission or two emergency department   presentations within the last year. In addition, adult patients who were prescribed at least 10 regular oral or inhaled, long-term medicines were also recruited. “When I say six or ten medicines, I don’t mean a couple of catheters and a couple of eye drops and some gluten-free breads – I mean proper systemic medicines”, emphasises Mr Williams. The medicines optimisation intervention was essentially a structured medication review, during which a list of medicines-related problems (MRPs) was compiled and the Medication Appropriateness Index (MAI) was calculated. Patients were also asked about their beliefs about medicines and quality of life.  “If you were in the intervention group you saw somebody like me for a structured medication review at month zero, then you saw me at month two and   then at month four and then it was all wrapped up by month six”, says Mr Williams.

Research findings

The results showed that, as a result of the intervention, the number of medicines-   related problems was reduced. “A lot of that was to do with adherence or adverse drug reactions or people being on inappropriate medicines that were no longer necessary”, recall Mr Williams. The Medicines Appropriateness Index was also significantly reduced.  “Interestingly we were able to show that it reduced the number   of telephone consultations that were made to the practice if you were in the   intervention group”, something that is an important consideration for a busy general practice.  There are almost certainly too many confounding factors to allow a study such as this to demonstrate reductions in the risks of death or hospitalisation, he says.

“I think what this study adds – and this is my personal view – is that if you can increase the quality of life for patients and you can reduce the number of contacts with health professionals then that is a good outcome. I’m not sure whether or not you’re ever going to be able to prove that [the intervention] will increase your life or reduce the risk of you going into hospital”, says Mr Williams. He notes that further trials are planned to look at this issue. In conclusion he says, “It was a fantastic experience and I loved it and of course I still see some of these patients who took part …… it was lovely and it was good to see that it was finally published.

Reference

Syafhan N et al. General practitioner practice‑based pharmacist input to medicines optimisation in the UK: pragmatic, multicenter, randomised, controlled trial. J Pharm Policy and Pract (2021) 14:4 https://doi.org/10.1186/s40545-020-00279-3

Steve Williams MPhil, BPharm Hons, Clin Dip Pharm, Pharmacist Independent Prescriber, MRPharmS is a Senior Clinical Pharmacist Poole Bay & Bournemouth Primary Care Network. He is also the Founder and Director of One Less Pill Medicines Optimisation Consultancy. You can keep up to date with Steve Williams on Twitter.

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

Mr Williams and his team routinely deal with a wide range of medicines-related and prescription-related queries from doctors, paramedics, physiotherapists, nurse practitioners, practice nurses and other clinicians in the practice. The PCN serves a total of 40,000 patients and issues prescriptions for some 800,000 items annually. In order to handle the work efficiently it is organised in a virtual pyramid in which prescription clerks and pharmacy technicians handle the routine queries at the base and pharmacists are free to deal with more complex issues. It is important to ensure that “you only have the people at the top doing the things that only they can do”, says Mr Williams.

Much of the work concerns medicines reconciliation – when, for example, patients move from secondary to primary care – and ensuring that records are updated appropriately. Other important tasks include providing appointments for patients who need medication-related consultations and dealing with medicines in care homes. Pharmacists also undertake structured medication reviews that involve “talking to patients about their medicines and trying to find out what’s important to them and trying to optimise their medicines”, explains Mr Williams. Because of his clinical skills and previous experience, he is also able to provide chronic disease management consultations. So, for example, “if they’ve got diabetes and asthma and atrial fibrillation instead of them having to come back and seeing the asthma nurse three months later and then the diabetic nurse six months later, I can actually do it all at the same time”, he says.

Strategic functions

Mr Williams says, “I’ve always said that thinking is very underrated in the NHS but I do a lot of it. You have to make time to think, you have to make time to listen, you have to make time to lead..….. Clinical leadership requires people to think about, ‘how do I fit in?’  The concept of the ‘influence onion’ is helpful here, he says. “If you’re a pharmacy professional working in primary care you’ve got to think about all the people that you can influence but all the people that also influence you…. we don’t want people doing jobs as pharmacy professionals that could be done by somebody else in the practice”.

Pharmacy technician role

The working relationship between pharmacist and pharmacy technicians is synergistic, according to Mr Williams. “You work together to be able to provide   better care”, he says. One critical step in the development of services in the PCN where he works was building a proper understanding in the organisation of what pharmacy technicians could do. Primary care tended to view technicians as people who, for example, took blood or performed Doppler tests but were not able to offer an interpretation. The difference with pharmacy technicians is that they are able to offer interpretations of clinical findings, says Mr Williams. Speaking of a technician colleague he says, “he’s got skills, knowledge and competence to do things that …. I don’t need to do – and general practice, I think, is really good at realizing that we don’t want to get somebody to do something that can be done by somebody else”. In fact, primary care offers real career opening for pharmacy technicians.

In summary, Mr Williams says that the Poole Bay and Bournemouth PCN has been very supportive and understanding of what pharmacy professionals – both pharmacy technicians and pharmacists – can do for the practice and the PCN.

Steve Williams MPhil, BPharm Hons, Clin Dip Pharm, Pharmacist Independent Prescriber, MRPharmS is a Senior Clinical Pharmacist Poole Bay & Bournemouth Primary Care Network. He is also the Founder and Director of One Less Pill Medicines Optimisation Consultancy. You can keep up to date with Steve Williams on Twitter.

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

Steve Williams is a senior clinical pharmacist at Poole Bay and Bournemouth PCN. Before taking up this position five years ago he had worked in hospitals for 25 years.    His last hospital job was as a consultant pharmacist in medication safety.

In essence his current job involves heading the team of pharmacists and pharmacy   technicians that delivers ‘medicines optimization stewardship’. This can involve “antibiotics, high-risk medicines, repeat prescription systems, audits, teaching – everything and anything to do with medicines”, he says.

Mr Williams say that the move from secondary care to his PCN role was partly prompted by the desire to achieve a better work-life balance.  The other factor was the realisation that many of the patients he dealt with in the medical admissions were suffering from avoidable severe harms as a result of “problematic polypharmacy”. He realised that he was on “the wrong side of the fence” and could probably make a bigger impact on the problem if he moved into primary care.

Mr Williams was fortunate to be in the first wave of clinical pharmacists in general practice. He acknowledges that “there have been pharmacists and pharmacy technicians working in general practice across the country for decades – it’s just [that] it’s been in small pockets”.  NHS funding of these positions is intended to improve patient care and save GP time which it does very effectively.  However, he emphasises that working out how to use his expertise most usefully took time. “I didn’t see a patient for a whole year and it frustrated me but I spent my time working out what on earth goes on in general practice”, he says. With the benefit of experience he says, “you probably need to allow six months for somebody coming in to   understand exactly what their role is and how they can how they can then start to help. You cannot expect people to start on day one and be able to be all singing or dancing – and to be honest – nobody can do that in any job”.

Steve Williams MPhil, BPharm Hons, Clin Dip Pharm, Pharmacist Independent Prescriber, MRPharmS is a Senior Clinical Pharmacist Poole Bay & Bournemouth Primary Care Network. He is also the Founder and Director of One Less Pill Medicines Optimisation Consultancy. You can keep up to date with Steve Williams on Twitter.

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