Integrated pharmacy - a model for the future

Dr Carole Buckley

The head of medicines management for Bristol PCT had a vision to put a prescribing support pharmacist in every practice in Bristol. Alaster Rutherford succeeded in achieving this, and his influence has continued with independent prescribing pharmacists in many practices in the area.

Alaster Rutherford's vision started the journey for The Old School Surgery in recognising and then realising the potential for integrated pharmacists and pharmacy into the primary health care team.

In 2002 Rachel Hall joined the practice for half a day a week as our prescribing support pharmacist and soon became an integral part of the practice team. We mentored her to become an independent prescriber, and in 2006, we changed her hours to full time at the practice as a clinical pharmacist. She remains in the post to this day, and last year became a partner in the practice having widened her role beyond treating patients to clinical management. Rachel divides her time between clinical practice when she sees patients with long-term conditions, conducts medication reviews, all aspects of the practice prescribing, and working with the practice manager to deliver the QOF and enhanced services. She continues to offer training to the primary health care team, including visiting medical students and doctors in training, and regularly writes articles for the pharmacy journals on her expanded role in the practice. Rachel has been accepted as a clinician in her own right by the wider health care community and makes her own referrals to secondary care as appropriate. Her area of specialist interest is diabetes and she contributes to the local specialist network. Her opinions have also been sought nationally on the role of the pharmacist in the future.

Alongside Rachel, we have an onsite pharmacy that is partly owned by the practice, and we are in partnership with another visionary pharmacist, Jonathan Campbell.

Jonathan and his pharmacy team share the practice facilities, and we combine social events so that all staff consider us to be one unit. This is clearly a business arrangement and we are mindful of the need to remain open and honest with the patients, and avoid any accusations of directing patients. However, the service offered by the pharmacy stands on its merits and patients are full of praise for the standard of care they receive. It offers every additional pharmacy service, and it delivers medicines to the homes of housebound patients.

The pharmacy is integrated in many other ways:

  • It has access to the practice EMIS computer system and, with the patient's permission, can look at their records.
  • It offers an enhanced service to over 400 vulnerable patients identified by the practice which includes regular review of compliance and a monthly phone call from the pharmacist to ensure all is well.
  • It provides a regular visit to the local nursing home from a member of the pharmacy staff to ensure appropriate use of medicines and to avoid waste.
  • It has over 50 per cent of patients with regular medication on repeat dispensing cutting the practice workload and improving medicines adherence.
  • It runs a minor ailment scheme that cuts the practice workload.
  • It is the first point of call for smoking cessation to the practice population - with one of the highest quit rates in Bristol.
  • It is active in promoting chlamydia screening with provision of prescriptions if the results are positive, which is very useful with our high student population.
  • It has instant messaging access to the prescribers so, when a drug is out of stock or there is a problem, an alternative can be offered without inconveniencing the patient.
  • It offers training for the doctors and medical students attached to the practice.

The combination of working with such dedicated and active pharmacists has resulted in the practice being well below its prescribing budget for many years, we also have a lower cost per item than both the PCT and national average. The patient pathways for safe use of medicines and prescribing review and reauthorisation are firmly embedded with well trained staff in both the practice and pharmacy.

In 2015 it is hoped that we will run a pilot to offer preregistration pharmacists the opportunity to spend time in the practice and pharmacy to get enhanced community training.

Pharmacists should be viewed as the well trained and dedicated professionals that they are, and that primary care can gain a great deal by working closely with them. It is forecast that there will be too many trained pharmacist over the next few years - unlike GPs and nurses, so consider the opportunity that can be gained by welcoming them to the practice team. 

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