Pharmacists in Primary Care Networks
We have co-badged joint statements with the Royal Pharmaceutical Society and the British Medical Association encouraging greater use of community and clinical pharmacists across Primary Care Networks (PCNs). The statements highlight pharmacists' expertise in medicines and how they can achieve better outcomes for patients as part of the wider practice team.
The Primary Care Networks and Community Pharmacists Statement encourages PCNs to consider how they can work together in supporting the health and wellbeing of the local population. For example, helping to address current workload pressures within PCN services.
The Primary Care Networks and Clinical Pharmacists Statement emphasises their role in integrating primary care with the wider healthcare team, including colleagues in community, mental health, and hospital pharmacy.
Primary care networks and community pharmacists
Primary Care Networks (PCNs) are groups of GP practices coming together across England to share resources and deliver place-based care to their patients and population. Collaboration will not be limited to GP practices as PCNs also present an opportunity for community pharmacists to better engage with primary care colleagues at an early stage. Pharmacists, in whichever setting they work, have a wealth of knowledge and expertise around medicines.
PCNs provide an opportunity for services to be delivered in a complementary way across general practices and community pharmacies.
How can PCNs and community pharmacists work together?
Community pharmacies are easily accessible particularly in areas of higher deprivation. They are trusted local points of contact at the heart of the community, with different opening hours to local practices. They enable people to walk in without an appointment and have access to the skills of a pharmacist. They often interact with vulnerable populations such as the frail, elderly, homeless or substance misusers. PCNs should consider harnessing these connections to inform the development of services focusing on their local patient populations at the earliest opportunity.
Community pharmacists may be involved with local quality improvement projects, such as reducing Antimicrobial Resistance (AMR), recognising early signs of sepsis and some are also involved in practice / real world research. As well as the safe supply of medicines and providing advice and support, pharmacists, and their teams also have a role in signposting to other local services, referring to link workers and providing advice and services around healthy lifestyles. This can help with workload for practices and services across the NHS, ensuring patients are able to access the right services at the right time. Pharmacists and PCNs can work together to build on this work and nurture new services for the benefit of their local population.
Community pharmacists provide medicines optimisation services which need to be integrated into local care pathways to ensure that care provision is joined up across the system and to avoid duplication of effort. Community pharmacists can support their colleagues in PCNs to deliver structured medication reviews (SMR) by supporting patient understanding of long-term medicines, supporting patients when they are prescribed new medicines, identifying and addressing inappropriate polypharmacy and identifying patients who may benefit from a SMR. Community pharmacists have a clear role to play in supporting people who have recently been discharged from hospital, ensuring any changes to medicines are continued in primary care and thereby preventing readmissions. The Academic Health and Science Networks (AHSNs) are moving this work forwards with the Transfer of Care around medicines (TCAM) project, which has demonstrated lower admission rates and shorter hospital stays for patients who receive community pharmacist follow-up consultations / reconciliation post discharge. This is now included as a medicines reconciliation service within the community pharmacy contractual framework (CPCF).
One of the major roles that pharmacists can play is in supporting the health and wellbeing of the population covered by a PCN. By 2020 all community pharmacies will be accredited as healthy living pharmacies (HLPs) and offer a range of preventative / public health services. They already can offer advice on healthy eating, stop smoking, sexual health and physical exercise, and can support people to stay well. Community pharmacists are well placed to assist in the management of long-term conditions, supporting self-care and improving person centered outcomes. As PCNs develop this can be developed into more innovative models that explore other prevention and public health services.
Community pharmacists are supporting urgent and emergency care, for example, those who require an urgent supply of a medicine to help relieve the pressure on general practice and wider NHS teams.
Community pharmacies should be the first port of call for minor ailments with GP practice staff and NHS 111 referring people to their local community pharmacy for such conditions but in time people will go directly to the community pharmacy. Currently 20.4 million GP consultations are for minor ailments so using community pharmacists in this way will free up time in GP practices. This type of service is currently being piloted via the NHS Community Pharmacist Consultation Service (CPCS). Alongside this, there are opportunities to explore how community pharmacies can contribute to PCN extended hours DES.
How delivery of the seven new network service specifications will happen needs to be explored with the potential to look at how non-GP providers can support this delivery. For example, community pharmacists can support by identifying early signs and symptoms of cancer and CVD. A hypertension and atrial fibrillation case finding service will be piloted as part of the CPCF. PCNs offer the opportunity for pharmacists across the network to support and mentor each other and for the professions to promote both interprofessional and intra-professional working. This could be enhanced via training hubs, which are being developed across the country, providing multidisciplinary training and education for all professionals working in an area.
The BMA, RCGP and the RPS encourage collaboration between community pharmacies and PCNs to deliver optimum local population health. We encourage all PCN clinical directors to consider how community pharmacists can be partners in supporting the health and wellbeing of the local population, including helping to address current workload pressures within PCN services. In order to maximise the potential of the PCN contract, joint-partnership and collaborative provider models should be considered.
Currently some community pharmacists are qualified as independent prescribers but are unable to fully utilise their prescribing qualification. We would like to encourage the greater use of pharmacist prescribers across the PCN with appropriate clinical support, so they can better support the delivery of care and care closer to home. NHS England have developed the Primary Care Network (PCN) contract and have provided guidance for Local Pharmaceutical Committees (LPCs) to help facilitate engagement with the PCNs. All PCNs will need to engage with the non-GP providers, including community pharmacies, by April 2020, but many are likely to do so before this date.
Community pharmacies within a PCN boundary should begin by considering how they might engage with the network and what their offer to their PCN could be. This could be facilitated by the LPC and involve working with the Local Medical Committees (LMCs), Clinical Commissioning Groups (CCGs) and PCN clinical directors. PCNs may find it helpful if there is a single point of contact to engage with in relation to the community pharmacies within the area, although this may depend on local circumstances. This is being encouraged via the new Community Pharmacy Contractual Framework (CPCF).
- Community pharmacists need support with infrastructure to help PCNs even further, in particular:
- Access to relevant electronic patient information in order to deliver seamless care for patients and to the ability to share information on intervention they make as community pharmacists. This needs to include the delivery of interoperable systems across networks.
- Mechanisms and clinical standards to make referrals from community pharmacies to GP practices so that systems are joined up and share relevant information.
- Local training hubs will need to work to cultivate a sustainable, flexible, effectively skilled workforce with the potential to develop team members to deliver care across different parts of the system.
- Support for pharmacists within a network to cooperate and work collaboratively to provide effective and sustainable services across a PCN.
The RPS will work with the BMA, RCGP as well as other key stakeholders such as NHS England / Improvement to promote the community pharmacy workforce to GP practices and PCNs. We will provide assistance and advice to both GPs and pharmacists, respectively, to ensure that PCNs engage with community pharmacy and integrate community pharmacists into PCNs. We are all healthcare professionals that want to work across the systems to provide the best care we can to patients and the public and ensure they get the best outcomes from the interventions and treatments provided.
Primary care networks and clinical pharmacists
Under the Primary Care Network scheme, announced as part of the 2019 GP contract, all Primary Care Networks (PCNs) will be able to claim up to £37,810 reimbursement towards the cost of a clinical pharmacist to work across the PCN. This will expand over the next 5 years so that by 2023/24, a typical network of 30 - 50,000 patients could choose to have its own team of approximately six whole time equivalent clinical pharmacists.
Within primary care, clinical pharmacists work as part of a multi-disciplinary team (MDT) in a patient facing role to clinically assess and treat patients, using their expert knowledge of medicines to add value to and to improve patient care and patient outcomes. The role of clinical pharmacists working effectively within a general practice setting has been demonstrated over recent years, with the Clinical Pharmacists in General Practice programme. This initiative has placed over 900 additional clinical pharmacists into primary care. Employment models and the roles and responsibilities are varied. They aim to make full use of a pharmacist’s clinical skills and knowledge for the benefit of patients, to reallocate some tasks to alleviate workload pressures, and to enable GPs to focus their skills where they are most needed.
Clinical pharmacists are those pharmacists that have undergone an 18-month training programme commissioned by NHS England. The British Medical Association (BMA), the Royal College of General Practitioners (RCGP) and the Royal Pharmaceutical Society (RPS) support the important role that pharmacists can play within PCNs, practices and the wider primary care team. We support the expansion of the pharmacist workforce within general practice and care homes building upon previous programmes of work.
The majority of the clinical pharmacists’ role will be undertaken in consultations with patients, whether in the GP practice, care homes or as part of home visits. They will usually be independent prescribers, or will be completing training to become prescribers, and will work as part of the wider practice team, under the supervision of a GP. They will work closely with other members of the MDT in ensuring that patients with chronic diseases get the maximum benefits from their medicines as part of a shared decision-making consultation.
They will undertake structured medication reviews (SMRs) to proactively manage people with complex polypharmacy, especially the elderly, people in care homes, those with multiple co-morbidities, frailty and people with learning disabilities or autism.
Clinical Pharmacists provide specialist expertise in the use of medicines, helping to address both the public health and social care needs of patients within a PCN and they help tackle inequalities by helping to improve access to care. These pharmacists can additionally help to provide leadership on person centered medicines optimisation and quality improvement, contributing to the quality and outcomes framework (QOF) and enhanced services across the PCN. These pharmacists support patients to get the best from their medicines, reduce waste and promote self-care.
Clinical pharmacists will have a significant role in supporting further integration of primary care with the wider healthcare teams, particularly with their clinical colleagues in community, mental health and hospital pharmacy. They will work with pharmacists across the system to help enhance patient outcomes, delivering improved access and seamless care as patients move between providers. The role has the potential to significantly improve quality of care and safety for patients. Clinical pharmacists will play a key role in helping to deliver the new network service specifications, particularly the delivery of the structured medication reviews, enhanced health in care homes, delivering personalised care and supporting the work on cardiovascular diagnosis and prevention.
A number of clinical pharmacists will have taken on the role of clinical director within their PCN, alongside GPs and Advanced Nurse Practitioners. All clinical directors will play a critical role in shaping their network, working with all the members of the wider practice team to develop and implement services. Clinical directors will also need to work with their respective Integrated Care System (ICS) / Sustainability and Transformation Partnership (STP) to ensure proper representation of primary care in developing local plans to implement the NHS Long Term Plan.
Clinical pharmacists could play a leading role in progressing medicines safety and optimisation across a mature PCN. They could ensure that appropriate processes and procedures are in place to reduce risks of medicines harm and work with other healthcare professionals and patients to ensure that their medicines are right for them.
They will be involved in quality improvement initiatives targeted at their local populations, supporting the delivery of the QOF. Clinical pharmacists will need to be able to access CPD and training opportunities as members of the primary care team, as well as contributing to the development of others where appropriate. This would include opportunities to develop leadership skills and work with PCN leadership teams in developing strategy and operational delivery across the network.
As networks become more mature, the role of a consultant PCN pharmacists could be developed to support system leadership across a PCN and an ICS / STP.
The RPS will work with BMA, RCGP and other key stakeholders such as NHS England / Improvement to promote the role of clinical pharmacists within PCNs to both GP practices and pharmacists. We will provide assistance and advice to both GPs and pharmacists, respectively, to ensure that practices are able to provide a supportive working environment and that pharmacists develop the competence and confidence to consult directly with patients, becoming autonomous independent prescribers working within a multi-professional team.