PCN pharmacists: How the most popular ARRS role works in practice

Victoria: Could you start by giving a brief overview of how pharmacists are deployed in your PCN?

Stefan: We’ve had pharmacists from early on; one of the first members of our ARRS workforce was a pharmacist. Our four practices are of similar size, so we recruited pharmacists and embedded them in the surgeries to support daily work. They also do some work on the PCN requirements for the contract.

We now have five pharmacists, all independent prescribers. They’re probably the most useful ARRS workforce we have and help to reduce the practice workload. They’ve taken over long-term condition clinics like hypertension or statin prescribing and reviews. They are very integrated in our team now.

They’re probably the most useful ARRS workforce we have and help to reduce the practice workload.

Dr Stefan Waldendorf

Chibby: Like Stefan, we’ve employed pharmacists from the get-go. We’re an 85,000 patient PCN and we’ve got seven pharmacists spread across 10 practices.

We’ve got some pharmacists working centrally to deal with structured medicine reviews (SMRs) and projects, while others are working in practices. We’ve got a pharmacist lead who is involved in training and development and five to six prescribing pharmacists who do UTI audits, pain management clinics and prescribe opiates.

We’ve also dabbled in the murky waters of ADHD, helping to sort out a shared management plan with the main provider. And we’ve recently started a weight management service led by the lead pharmacist and myself.

We also do a lot of care home work and we’ve had a bit of involvement with pharma with medicine optimisation.

As a team, they’re growing and will continue to grow. The cost savings are really beneficial.

Viren: I believe I was the first ARRS member in our PCN. We’ve got seven surgeries and two pharmacists so we split our time across them. We have had other pharmacists, but the majority of them come, are trained up and then they leave. I don’t know how you guys are keeping pharmacists within your PCNs.

Seemal: I’m a lead clinical pharmacist for my PCN. We have six pharmacists across five practices, aligning one pharmacist per practice and I have one day a week doing work for the PCN as a whole.

We have a big role in terms of managing our care homes, the management of medications and answering any queries. We attend multidisciplinary team meetings (MDTs) for care homes and others too, such as diabetes MDT and heart failure MDT. We’re involved quite strongly in chronic disease management and managing QOF targets for practices.

We continue to do targeted SMRs and we’re tackling polypharmacy as a big project at the moment. And we’re setting up specialist clinics, such as a hypertension clinic, which involves diagnosing, organising further investigations, starting and titrating medications until patients achieve normal blood pressure.

Alan: We’ve got four pharmacists and we work in a PCN hub, not the practices. We’ve got four pharmacy technicians across six practices.

We get sent quite a lot of tasks from the practices to support them, such as medicines reconciliation, medication reviews, and SMRs as well. And there’s more we want to start adding – we’re looking at QOF, CQC searches and MHRA alerts.

Jasmin: Under ARRS, there’s me and two other pharmacists. We also have two technicians and we’re currently advertising for a third.

We also have an ICB-funded pharmacist doing our care home and frailty work, who’s supported by the technicians.

The pharmacists work across three practices and we have four out of five days when we have face-to-face clinics in the practices. We do healthy heart reviews, type two diabetic review clinics, and cholesterol hypertension clinics.

One of our practices uses us for triage to fill appointments, which is quite fun because you never know what you’re going to get.

And NHS Dorset is doing the pharmacy quality scheme, which has various targets for us to achieve. That’s to do with prescribing and trying to reduce spending.

Henry: We’re actively looking at employing another pharmacist to add to the team. Pharmacists have made a huge difference to GP workload.

Interestingly, the practices each find their own uses for the pharmacists and have slightly different approaches, but the evidence is that they find them beneficial in the amount of workload that they relieve.

In fact, we’ve had to take a very careful look at the consultations because sometimes they’re a little bit past what a pharmacist is trained to do so we’re looking at criteria and rules for appointments. If it’s outside a pharmacist’s training, we’re not saying that the pharmacist won’t do it, but we discuss further training or sitting in on clinics to train up the pharmacist. And we also ensure that there’s ongoing work so that the pharmacist maintains that experience.

We’re actively looking to further extend the pharmacist role, over and above the contractual work and the bread-and-butter type work.

Neil: We work slightly differently in that we work under the umbrella of Sutton Primary Care Networks. Under that, we branch out into four PCNs; I’m lead pharmacist for Central Sutton PCN and there are three others.

We’re all independent prescribers. We’ve hired four pharmacy technicians in the last month as well.

I’ve got my own hypertension and lipid management clinic, which I run at my PCN two days a week. As a PCN, we work closely with University College London (UCL) partners, so there’s been initiatives, such as the Healthy Heart Clinic, where we’ve targeted patients who are reluctant to come to the GP practice – the ones with raised blood pressures who don’t engage. We’ve done face-to-face and telephone clinics with those patients.

We’ve also had the virtual ward for patients who are ill, but not ill enough to go to hospital. We’ve worked with consultants to manage them and make sure they don’t take that next step of going into hospital. As pharmacists, we’re looking at the medication they’re taking, if they’ve got a pill burden and what we can do to reduce it.

In southwest London, we piloted a hypertension case finder service where we’ve upskilled community pharmacists to diagnose and treat basic hypertension patients. They’ve got EMIS on their system and they work closely with us. They’ve shadowed us in the GP practice too. They’re prescribers as well.

Victoria: What are the benefits of ARRS pharmacists to a PCN? Do they ease GP workload and how does that work from pharmacists’ perspective? 

Henry: We have a triage hub system. It’s a reflection on the effectiveness of the pharmacy input that waiting times for appointments with general practices have reduced. I think GPs have gone from 10-minute appointments to 15-minute appointments, suggesting a significant freeing up of time.

Stefan: For the last two years, we’ve been triaging to sort which clinicians the patients will see, and we found that a lot of requests can go to pharmacists instead of a GP. Our pharmacist deals with most medication queries now, and things that were handled by GPs, if you go back 5 – 10 years. It has freed up GP appointments for others.

On the other side, it means that the GP appointments are more complex because all the easy patients go to pharmacists.

Chibby: It’s the same for us. Everything is done centrally by a pharmacist because we’ve got a hub and the work is delegated. We also centrally triage all our online consultations. That’s improved the workload for GPs and helped release capacity.

Jasmin: Since I joined Jurassic Coast PCN, I’ve never had a day when I thought I’m not being stretched enough. It’s a very full-on role and they’re always thinking of new ways that they can use us.

For example, I work two days a week in one practice and I started off doing SMRs then stepped into doing a bit of hypertension and now, all of a sudden, I’m doing all the care plans and reviewing of type two diabetics.

So, we’re very lucky in the sense that the practices want to keep extending our competency and our scope of practice.

But the flip side is that sometimes we’re pushed a little bit too far and we have to know our limitations and know when to say: ‘This is for a GP. This is not for us’.

Victoria: Is it a common issue that pharmacists are being asked to do things beyond scope? Do clinical directors find it tricky to work out what a pharmacist’s scope or competency is?  

Henry: As a GP, I feel like I’ve expected quite a lot of the pharmacists and not been entirely aware of where their skills stop and where the interface is between what a GP and a pharmacist would do. It’s clear that it’s flexible and it needs attention to detail.

For example, in the triage hubs, a problem might arise when a patient says they want to start an antidepressant. The admin staff have seen it as a medication query so put it to the pharmacist. But at that point, the patient hasn’t even been diagnosed with depression. The pharmacist may be happy to titrate up an antidepressant, but they shouldn’t be asked to make a diagnosis of depression, certainly not without significant further training.

It all comes down to being specific about what people’s skills are and what their training is and making sure that everybody involved in triage knows that.

As a GP, I feel like I’ve expected quite a lot of the pharmacists and not been entirely aware of where their skills stop

Dr Henry Pearse

Alan: When GPs qualify, there’s a standard scope of practice for every GP, but pharmacists come from very different backgrounds. I came from a hospital before primary care, whereas my wife who’s also a primary care pharmacist, came from the community. So our skills and competencies can be quite different and that can be confusing for GPs at the practices.

I developed a competency matrix and shared that with the practices so it’s clear what they can put to which pharmacist. Also, we use System One, so you can hover over the med review slots and it’ll say what reviews can be booked for each pharmacist, depending on scope. So, I can do contraception and HRT, but other pharmacists might not have those skills yet.

Neil: Just as pharmacists bring different experiences to the table, the same is true of GP practices because every practice has its own vision of what it would like a pharmacist to do.

There was one practice using them for admin, rather than clinical, because they didn’t really understand the role of a clinical pharmacist. And we’ve lost experienced pharmacists in the past hence why we’ve now hired pharmacy techs in our PCN.

Victoria: Viren, you mentioned that your PCN struggles to retain pharmacists. Is a lack of understanding of the role a reason for this?

Viren: For us, it’s the salary side of it because they’re coming from community pharmacy. So they’re either locums or already on higher pay and it’s much lower than that in GP land.

Chibby: We decided in our network to make sure of fair progression. We’re not Agenda for Change, but we do have a competitive structure.

Our HR manager has created a structure where competencies for these clinicians, especially the pharmacists, are ratified by the lead pharmacist and the pay progression is then offered to the person. It has to be fair, otherwise you’re just going to lose these very valuable members of the team.

It was a hard journey, but anything to do with pay is hard. It matches the ARRS allocation, but for some roles, such as our lead role, we sometimes have to top up.

Stefan: Pay is always a contention in PCNs because we’re limited by the funding we can claim through ARRS. We try to stick to that because we have no other buckets of money to top it up but we do it occasionally. We have a lead pharmacist who is paid a little bit more, but he has some supervising and training for other pharmacists.

And we have employed pharmacy technicians to help with the daily workload. It does help to develop a skill mix in your team – people who can support the pharmacist in a way that is valuable.

Just coming back to the retention and the training, you need to invest in your staff as a PCN. The key thing is the ethos of support in your PCN. You develop staff and that’s how you can retain people because you have experienced staff who are happy to work in your team.

Victoria: How do you work with Pharmacy First? And do you work closely with community pharmacies? 

Neil: Yeah, we work very closely with our community pharmacies. We try and engage community pharmacy to join our clinical meetings every quarter for updates.

Earlier, I mentioned the hypertension case-finding pilot where we’ve empowered community pharmacists who are prescribers to titrate antihypertensive medications for patients. They work closely with us in general practice. As well as the GP, they can request bloods and the bloods come back to them so they can review the user’s needs, for example. So, there is a big push in our PCN in terms of working with community pharmacy.

With Pharmacy First, we initially had pushback. At one of the practices, the triage system is excellent and they were like: ‘We’re doing all the questioning and all the work and the pharmacy is getting all the money. Where’s the money in it for general practice?’

But inviting community pharmacists into practice and explaining how much time will be saved went a long way and slowly, slowly, we are seeing our numbers increase.

With Pharmacy First, we initially had pushback…But inviting community pharmacists into practice and explaining how much time will be saved went a long way and slowly we are seeing our numbers increase.

Neil Desai

Alan: We’re trying to develop a pro forma that community pharmacies can use to communicate to us about [medication] shortages. Shortages are crippling us at times – the amount of time it takes to sort through is quite frustrating, and some of the online resources we use to manage that just aren’t up to date, which can be challenging.

So, we set up a generic email inbox so they can tell us what’s out of stock and potential alternatives that might be available, which means we’ll prescribe the alternative if appropriate.

Seemal: We have a specific hypertension case finding service and work closely with our community pharmacies utilising their ABPM check. Over the last four months, we’ve sent over 250 referrals to our local community pharmacies for ABPM checks and identified lots of new hypertension cases.

Obviously, they get financial remuneration from us referring blood pressure checks to them and, at the same time, it’s an appointment saved for us. So, it’s a win-win situation.

We’ve also done a few community outreach projects together, trying to proactively identify new hypertension cases. That involved members of the PCN team – care coordinators, nursing staff and clinical pharmacists – as well as some community pharmacists.

With Pharmacy First, we have regular meetings, bringing everyone to the same table to have a discussion and go through some of the referrals. If things are coming back, why are they coming back? It’s just having an open discussion as to how things can move on. It’s helping improve the service and relationships.

Jasmin: Our relationship is nowhere near as positive with Pharmacy First. Our Pharmacy First scheme is not used as much as I would like and there are a lot of elements that are causing that problem.

Over the last year, we’ve lost three community pharmacies, which obviously then impacts the remaining pharmacies. They’ve had to cope with a huge influx of patients, which means that the amount of dispensing that they’ve now got to do is unsustainable.

In addition, one of our main practices has a really good triage system in place so getting them to engage with Pharmacy First is difficult. I’ve tried to push it, but in their eyes, if it’s a simple UTI, it’s a quick fix, so they might as well do it rather than batting it to the pharmacy. That isn’t helped by the fact that we get quite a lot of pushback from the pharmacies if the patient doesn’t fit the specification.

Stefan: We are probably one of the highest users of Pharmacy First in our area.

Initially, there were situations where a lot of patients got sent back and there was confusion. But if you have a total triage system, we have a little list of the qualifying criteria as clinicians who are sending patients, and we send them to Pharmacy First directly.

That works quite well and now we have a very low return rate. They got used to getting these patients and they probably got skilled up over time to be able to provide the service.

Victoria: What is the future for pharmacists in ARRS and PCNs over the next five years? And how will you support the new cohort of independent prescriber (IP) pharmacists as finding placements in practices has been a challenge?

Neil: We’re doing a six-month placement with community pharmacy and our PCN. We’ve got three foundation trainee pharmacists and I’m designated prescribing practitioner (DPP) for one of the new cohorts. In January, we’ve got three more switching for another six-month placement.

This ties in with the retention side of things, which is what I pushed with the clinical directors in our board meetings. It’s a business for them so it all comes down to money and the first question is: would we get money for this? Unfortunately, the answer is no, but the long-term benefits outweigh the short-term gains for sure.

The trainees that you’re training up are with you for six months and you can mould them in the way you want. If for any reason, you were to lose an experienced pharmacist, you’re in a better position to recruit someone quite quickly and easily.

Seemal: I’ve got two pre-registration students who will be qualified as independent prescribers, and they are with me two days a week, every week. It’s been really helpful.

We’ve obviously had to train them up, get them used to the IT systems, etc, but it’s been really good to give them projects that help the practices and the PCN. They do pieces of work like drug monitoring, for example, or CQC searches.

As a single pharmacist in a practice of 30,000 patients, it’s just impossible to tackle some of these searches, so having that extra help has been beneficial.

Jasmin: I would have been terrified if I’d come out of my pre-reg as a prescriber knowing what I know now, compared to what I knew five years ago. So, I just hope that there are going to be things in place to give them the support that they need and that they know their limitations with regard to the scope of practice and prescribing.

As for the future, I am not one to toot our own horn, but I don’t know what the practices would do without the pharmacy team. I can’t see a future without pharmacists in primary care.

I think the future of pharmacy is utilising the pharmacy technicians to do so much more than discharge summaries and care home medicines reconciliation. So, I think the main focus in the future is actually getting the technicians to have more of a clinical role. That’s what I’m aiming for in our team.

As for the future…I don’t know what the practices would do without the pharmacy team. I can’t see a future without pharmacists in primary care

Jasmin Kilby

Viren: With independent prescribers, the good thing is in terms of support, that they don’t necessarily have to prescribe themselves straight away. They could start up the medication and then send it to a GP or someone to sign off. That’s a good way to get them used to what sort of monitoring to do and it will increase their confidence.

We’ve also got options to start them in just hypertension, for example, and build their way upwards. And they can shadow either doctors, nurses, or other pharmacists.

The problem could be if there are independent prescribers who start prescribing anything from community pharmacy without any support. I think that’s where most of the issues tend to happen.

Victoria: Is there a concern that there may be a repeat of the physician associate (PA) issue with new IPs around their level of responsibility for patients?

Stefan: It’s a different starting point with pharmacists. PAs were artificially designed. After a two-year course at uni, they were expected to be able to work in a primary care setting independently.

It’s different with pharmacists because they are experienced, accredited clinicians when they come to us, and we just shape them to work in primary care. And I think that has worked.

As for the future, the future for PCNs is going into neighbourhood services, and pharmacists will have a role to play in providing services across the patch, rather than on a practice basis now. I think we will lean more on our pharmacists as a team to provide additional services.

It has reached a point where practices would probably be happy to pay to have pharmacists because they have demonstrated their value.

Alan: We’re so well embedded in primary care that I don’t know how you’d unpick that now and take us out of it. And I don’t know how GPs would cope without a clinical pharmacy service.

It’s the same for pharmacy technicians, who have followed on from the pharmacists. We’re putting the pharmacy techs through vaccination training at the minute, so they’re going to be able to support that too.

Henry: I think teaching, training, and shadowing as a way of developing staff in order to retain them is really something we could look at. So, there’s a big hope and expectation for the training side of things.

This roundtable was one in collaboration with sister title The Pharmacist.