What roles and responsibilities do Clinical Pharmacists have in the NHS? How can Pharma and Medtech engage Clinical Pharmacists, and how can industry best support these new decision-makers?
Tom Clarke (Director, Mtech Access) explores all this and more with Tom Kallis (Senior Clinical Pharmacist, East Cornwall PCN).
They explore the origins of the Clinical Pharmacist role and how it has become a key part of the primary care landscape, to understand how the responsibilities of those in the role have been growing. They discuss examples of specific, surprising, ways in which Clinical Pharmacists are expanding their skillsets and doing far more than just medicines use reviews and signing off prescriptions.
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What roles and responsibilities do Clinical Pharmacists have in the NHS? How can Pharma and Medtech engage Clinical Pharmacists, and how can industry best support these new decision-makers?
Tom Clarke (Director, Mtech Access) explores all this and more with Tom Kallis (Senior Clinical Pharmacist, East Cornwall PCN).
They explore the origins of the Clinical Pharmacist role and how it has become a key part of the primary care landscape, to understand how the responsibilities of those in the role have been growing. They discuss examples of specific, surprising, ways in which Clinical Pharmacists are expanding their skillsets and doing far more than just medicines use reviews and signing off prescriptions.
Subscribe to our newsletter to hear more news, insights and events from Mtech Access.
- Good afternoon, and welcome to the latest Mtech Access Words of Wisdom webinar. I'm Tom Clarke, and it's great to be back speaking with another one of our fantastic NHS Associates to understand a bit more about what's really happening out there. We're a couple of weeks away from the formalisation of ICSs, and there's much strategic stuff going on at the moment that we'd normally be getting stuck into such as the Fuller stock take and all the headlines from NHS ConfedExpo. This month, though, we've decided to get into the detail and through a lot of conversations that we've had over the last couple of years, clinical pharmacy, clinical pharmacists is one thing that keeps coming up. The role is not a new one, but an evolving one. And many of our audience are trying to understand just what this role is, what the responsibilities within it might be, and the influence that clinical pharmacists might have going forward. So to help me demystify some of that today, I'm joined by Tom Kallis, who is the senior clinical pharmacist for East Cornwall PCN and lead pharmacist with Devon Local Pharmaceutical Committee. Tom's an experienced prescriber and manager of prescribers with former experience in PCT work, as well as community pharmacy. So Tom, welcome, thank you for joining me today. Just to open up, please, could you just introduce yourself briefly? What is your current role, and can you give us a bit of a view of the system that you're working in?
- So Tom, pleasure to be here, thank you for having me. My name's Tom Kallis. I'm the clinical pharmacist and for the East Cornwall Primary Care Network, and that's my full time role. I do four long days, and I'm also project pharmacist at Devon LPC for one day a week. So really, what my split of the role is, is in my PCN role, I'm split about 50-50. So 50% of my time is spent doing clinical work. I run my own clinics. I have an interest and specialism around chronic pain management and also the deprescribing and management of medicines at high risk of addictional dependence, including things like benzos and Z-drugs for management of insomnia. But that being said, I have that specialism, but in general practice primary care it's whatever rocks up onto the list during the day. It's all of those other meds management tasks, as well. And the other half of my kind of health role is really focused on development, management, and delivering clinical supervision to our clinical pharmacists. So when I joined the network, it was just me. Whereas now, we've got a fantastic team of eight clinical pharmacists and a growing team of pharmacy technicians, as well, which I lead. And it's very much a learning culture that we're beginning to foster. And we also have a number of different innovative projects that we're doing. And that comes into that other half of the role. With regards to Devon LPC, so the Local Pharmaceutical Committee, is the statutory representing body for community pharmacy. That role is hosted in Devon, and for that day a week, it's very project-focused, again, and educational element around working out presentations and learning packages for pharmacy contractors and pharmacy teams in the community, as opposed to just primary care, around contract changes, clinical updates, but also thinking about system integration and how does community pharmacy get involved with supporting the wider NHS system. And I know that's very topical at the moment, certainly with Sajid Javid's recent announcement that it's going to start with community pharmacy. So who knows what that means, but that's the spread of my roles. My week is, it's very diverse. No two weeks look the same. So more than happy to dive into a bit more detail if need be.
- Fantastic, thank you, Tom. Already, just in a couple of minutes, you've given us a really good perspective on how broad the role has become. Like you said, you started out just you, and now you're doing all of those things. So as I mentioned in the intro for a lot of our audience, clinical pharmacy might be quite a new role to them I suppose in different parts of the country it's moving in different paces. Could you just sort of give us a bit of the context of where the roles come from and a little bit about the evolution to date, both kind of for you locally and then maybe on a more national level?
- Absolutely, so clinical pharmacy and primary care has really evolved over the last three to four years. It's very much coming around the inception of primary care networks. And there was a recognition that the pharmacy workforce is still under-utilised within the NHS. So if we wind the clock back about five years, there were initial trial phases, called waves, through NHS England, employing pharmacists directly through GP practices and funding came attached to that. Basically, it was building the pharmacist role within GP practice teams and those successful pilots eventually led to the clinical pharmacist role being an embedded part of the PCN additional roles reimbursements. So essentially, when PCNs were formed, the first role that was available to be employed were clinical pharmacists, and the other roles quickly followed in subsequent years and months. There is a recognition that pharmacists are under-utilised, especially in primary care. So the role is very much forming in different Primary Care Networks are at different levels of formation. And what you'll find is that one pharmacist is used very differently from one practice to another, let alone from one PCN to another. There's certainly lots of different things that we've got to deliver. So there are several projects and pieces of work that pharmacists can get involved with in practise, whether they're prescribers or not. But also, there are now new PCN indicators that are linking with the NHS long-term plan around prescribing, medicine safety, and also population health level management, which pharmacists can get involved with. And very much that workforce will be being pulled into delivering some of those larger and wider PCN projects. So real variation in terms of workforce. And there's a lot still to be done in terms of education and development. The story's very much evolving.
- Yeah, fantastic, thank you. I was working in primary care myself when those first waves came through, and I remember conversations within practices about, okay, well maybe there's some funding, but what do we do with a pharmacist in a practice. In terms of how that's evolved, and obviously you've talked about different people doing that in different ways, has there kind of needed to be a bit of a exercise in building trust in the capabilities of pharmacists? Has it been a battle to get pharmacy recognised within practices and PCNs, or has it been kind of open arms of please come and help us out?
- I think very much it's the open arms approach, certainly when you're employing someone directly through your organisation or through a holding organisation such as the network, those barriers, especially as we see the barriers between community pharmacy and between primary care in some geographical situations, they very much fall away. So it's more about what can this healthcare professional do. That's usually the first question when a pharmacist starts and practises so well. So what can you do? And then, as time goes on over those subsequent weeks, months, certainly my experience in practice was like this that people realise, oh, you can do this, you can do this. And suddenly, the tap of work is opening up until there's too much. And then, that's the real valuable part where you can say, actually, what's the best value that I add into the practice? What am I going to do for the practice, and how much time am I going to spend on my PCN work versus the work that I'm going to do in practice? And if it's useful, I can dive into some of the bits and pieces that pharmacists usually get involved with in primary care and pull out what kind of levels of support and education those pharmacists need to do those different activities, if that's helpful.
- Yeah, so the team that you manage, are they each individually attached with one practice, or do they have cross PCN responsibilities?
- So the model that we run is an embedded pharmacist model. So we give practices an amount of time of an individual. We try and map one pharmacist into each practice. Our PCN is large. We've got seven GP practices that we support through our network. And what that means is that those pharmacists can become embedded team members within the practice. They can help out with day-to-day practice work, whether that be if they've got an interest in chronic disease, whether that be acute on the day stuff, or just the normal meds management, processing discharge summaries, and doing all of the bits and pieces around script requests, as well as their PCN work to deliver, as well. So the model that we run at the moment is that pharmacists are based in practice doing practice work, but also delivering larger PCN project work. We've got a team culture around our pharmacy team resource, but that's something which may change in the future where we begin to look at, actually, we've got enough workforce capacity within our organisation to start doing stuff remotely or at a PCN level in terms of our interventions.
- Brilliant, thank you. I think probably without speaking on everyone's behalf, within our audience, probably there's this understanding that most PCN or practice pharmacists are doing the kind of routine stuff that you've alluded to. You talked earlier about the pain clinic and your own interest. Can you share a couple of examples of, I suppose, maybe something slightly different, more surprising things that you were individually or as a team are doing that maybe our audience would not automatically think would be the remit of a pharmacist team?
- So I think often when people think about pharmacists in practice that, and I think this came around with those very early pilot phases, people think about someone in a small office, hidden way somewhere in the practice, not seeing patients, maybe signing repeat prescriptions, dealing with prescription queries, or processing discharge summaries. That's part of the role, but that's not true value. And so that's certainly something that we can get pharmacy technicians helping out with. 'Cause don't forget, those highly skilled, NVQ level three techs have good pharmacy experience. They can do a lot of that meds management, day-to-day work, as well. In terms of the stuff that clinical pharmacists do, which can vary from one place to another. So a key element of the PCN des was so direction had services. So the strings that the PCN money comes attached to when it's being given from central governance primary care networks is the structure medication review. What that is, is an in depth 20 to 30-minute review with a patient where you're not only looking at adherence and if patients are using their medicines correctly, but each one is reviewed individually around is the medicine efficacious? Does something need deprescribing? Has the renal function changed? Does the dose need changing? Is it managing the disease appropriately, as well? So it's that next level of nuance on from just doing a basic meds review to actually determining disease control, as well. And that's where those clinical decisions around escalating therapy or de-escalating therapy come in. That's a real core part of the PCN pharmacist role. There's also bits around, I mentioned acute on the day stuff. So pharmacists do get involved with becoming advanced clinical practitioners where they may review patients who come in on the day with acute illness or minor illness and be part of assessment teams, as well. Or they may have a speciality in a chronic disease and run their own chronic disease clinics. So that might be aligned to respiratory. They might do the as asthma and COPD work that you might expect to nurse be doing or diabetes. They may take ownership of that as well as doing their medication reviews and the meds management bits. But also, it's worth mentioning those other disease areas, as well, and the general work that rocks in. So I mentioned around my role, very much when I first started prescribing, the majority of my case load is around mental health. So I tend to get involved in the management of depression, anxiety, and that's something that really interests me, as well as the management of insomnia, whether that be acute or chronic, including things such as opioid prescribing in chronic pain. And there's a real national drive around deprescribing and helping patients to manage, who are given medicines that have the potential for addiction or dependence. And that's a real key theme around not only prescribing, but deprescribing and seeing are there inappropriate therapies that patients are maintained on, and how do we reduce or manage those doses?
- Brilliant, that's incredible insight, and a couple of follow-ups on there I suppose. In terms of that mental health piece, for you now in the role that you are performing in the interest you've got, does that make you sort of the go-to person for queries about mental health, particularly on the pharmacotherapy side of things? Would things automatically come via you?
- So I think certainly aligned to chronic pain and certainly aligned to Z-drugs. We are really fortunate in the practice that I do, my clinical practice, in that we have a mental health and well-being practitioner employed there, as well. That's another PCN role that's employed across the network. So that mental health nurse and I work really closely together around patients with mental health problems. And it's quite useful, because they're not a prescriber, whereas I am, and we give really holistic care together. So they'll often talk about those in-depth complex patients. So pathways of care and holistic management, whereas if there's queries around prescribing and Pharmacotherapy management, I tailor into that, as well. And also, I work very closely with our physiotherapists, because it's often they who see patients who are struggling with chronic pain. Or if they have lower back pain and there's no underlying tissue pathology, often they will do the assessments. And if they need support around pain management, which may or may not be in medicine, they're often booked into my clinic, as well.
- So thinking about that patient that comes in or is probably already known to the practice that has chronic pain, maybe anxiety, depression, who probably two, three, four, five years ago would've come in to see the GP a few times a year and had quite a sort of a episodic, stilted sort of level of care, might that person now come into the practice and not see a GP at all?
- So very much the centre of GP practice is still general practitioners. And it's really important that, if there are any decisions around care or if there's any escalation that the GP is supportive and is aware, but it's more about how do we work in an MDT approach. So that patient might be holistically managed by their GP. Whereas, they may first present to an assessment clinic with an acute illness and be seen by a GP or a paramedic or an advanced nurse practitioner. They have that initial engagement, but then actually, the GP might say, "Okay, well, certainly we can do something about your medicines. I'll book you in with our clinical pharmacist." And in terms of physiotherapy, we can get an opinion from from our physiotherapist employed in practice, as well. And it's thinking about how we become a team, and where that really comes into place are those patients who have complex polypharmacy who are prescribed lots of different medicines, they're multi-morbid, have lots of different conditions, and they may be under several different specialists working closely as part of an MDT to manage those bits of care but also to get our heads together and think about how do we give this patient the best care possible with the resource we got on the team. That's really important, as well.
- Brilliant, and so is MDT working more prominent than maybe it once was because you've got that team within the practise and roles such as yours, the mental health work, social prescribers, others sort of within those additional roles? Does that mean that you are just doing more MDT stuff than you would've been?
- So I think that we don't call it MDT, but it is MDT really. And we get a lot, even when I'm running my clinics, we get loads of queries throughout the day of different professionals popping in equally of knocking on the door of our physio-mental health practitioner or GP or diabetes nurse about patients I'm reviewing. So there's a lot more conversation with dialogue going on into practice. There's a lot more specialties we're beginning to tap into. So yes, there is that very much collegiate type of working. And I think ultimately, the model is, 'cause we know there's a big GP workforce crisis in primary care. And I think most healthcare professionals in general, there is a pressure especially in the Southwest where I'm based around the pharmacy workforce is what skills and resource do we have in the practice, and how do we help preserve GP time so the patients who need that GP time can have access to it? The patients who potentially don't need to be seen by that general practitioner, or indeed even seen in general practice all together are seen appropriately, safely elsewhere or with someone else.
- Yeah, okay. So thinking back to that first wave back in 2017, 2018, whatever it was, and let's try and see whether there's a case for clinical pharmacists in primary care, or let's try and prove the case. Do you think you're now at point where clinical pharmacists are almost indispensable to primary care and have made or almost demonstrated the business case as it were for sustained employment?
- So I think definitely clinical pharmacists have made the case and have demonstrated their value into primary care. I think depending on how innovative you want to get with your different models and setups, I think you could provide some level of service with or without almost any element of a professional group within a primary care setting. However, that being said, I think definitely the profession had a task ahead of itself at crossroad those five years ago around how do we demonstrate the value to the primary care system? I think that's been done. I think that it's been demonstrated as a valuable role and that comes through in terms of the employment. And I think the majority of PCNs still are looking for additional pharmacy resource. Even though we've got eight pharmacists, we're still employing more. And the feel from our practice is that we want more pharmacy resource, as well. So think there is a definite value around it. And then, it becomes a bit of that bun fight around what does that professional do in practice? 'Cause there is no shortage of work that pharmacists and technicians can get involved with.
- Yeah, yeah, and we'll come on shortly to the development side of things, and how do you get more people in, and how do you equip them. But just coming back to the role itself, I suppose, probably more so your role than your peers or your colleagues, what are the factors that influence your decisions around what areas to focus on? Obviously, you've got some special interests. There'll be system priorities and local priorities. How do you narrow that down?
- So that's a real balance and a real, I think that you'll get a different answer in each network that you ask that in because of the decision-making process. So obviously, we've got day-to-day work, we've got the bread and butter of general practice of keeping patients healthy and well. Then, we've got things such as QOF that links into those outcomes based frameworks around payments into GP practice. But now, we've got these new direct enhanced services that the PCN does want us to deliver, as well as the impact of the, well, the investment and impact fund, which is essentially outcome based frameworks for Primary Care Networks. Those are criteria of health indicators that need to be delivered on a network basis as opposed to an individual GP practice basis. So it's about how do we split our resource within the network to deliver, what are we going to engage with and really go hell to leather with, and are there criteria in there that perhaps are simply unachievable in the IIF in terms of the resource that we have, the capacity that we have? So for example, one or two of those indicators in the IIF, it's a massive amount of workload for your network. You're only going to get a very small amount of payment. It might be that the network takes a collect decision. And that's a conversation with, if there's a board of directors within that network, or what's the balance of power? Is it the Clinical Director deciding, or is it just one GP practice who is its own PCN? What do you engage with, what do you go for? And how do you make sure that whilst you are doing that additional work, the lights are still on, patients are still being seen, and patients are still being kept safe and healthy, as well? So there's a real nuance around that I'd say or vary from network to network. Certainly, it needs to be involving the partners, involving the practice managers and the strategic element of PCN workforce, as well as the clinical resource.
- Yeah, okay, that's really interesting. And would it be fair to say there's different drivers for different initiatives? So you talked there about the IIF and the DES, and fundamentally you're looking at how much are we going to get paid for delivering these nationally mandated or nationally, whatever the, the step-down from mandated is nationally recommended areas is. But then locally, you might think we've got real challenges with this population. You're not going to get any payment with it, but you see that as a need. So is it a bit of a balance of every potential thing is really quite a complex bit to unpick, to figure out how do we manage the resource, what do we get back from it, and is it the right thing for our population?
- Yeah, and ultimately the people we serve are the patients and the people we've got on our practice lists. So what's the right thing to do for our patients? And there might be very well that we have a bigger conversation around it. An indication that we maybe can't attain since too much work in there. But how do we work differently and smartly around it? But it has to boil down to we need to keep patients safe. We need to keep part... And there's big move towards not only treating patients, but keeping patients healthy, as well as the whole ethos of the Primary Care Network around working with third-party providers and bringing other clinicians in. So I think the story doesn't stop with just, actually, we're not going to go for this one. It's actually, we can't deliver this one now, but how can we deliver it next year? Or who might we begin to think about working with so that we can deliver it in time to come?
- Yeah, yeah, and that's a really interesting point about the working with partners, because in terms of the broad assist ICS set up, it's looking at kind of aligned pathways and payments across a whole pathway of care. Is that something that you are starting to do yet, working with mental health providers, your acute trusts, third-sector organisations to start thinking about how you're all doing bits together, or you're not quite there with those bits yet?
- So I think definitely we're beginning to have conversations within our ICS around how we work differently, who hold certain people's employment. Are there other cross-organisational roles or roles which have put self-contained portfolios across, say, the local foundation trust. The ICS is still an evolving beast. So it's coming into formal legality very shortly, but the scaffolding, the infrastructure is beginning to build around that organisational piece. Thinking about third party providers we work with, the volunteer centre has been absolutely indispensable to us, a network, especially when we were hit with the unprecedented demand around to delivering those COVID-19 vaccinations. We could not have done that valuable piece of work that we delivered without our fantastic volunteers in Cornwall and everyone who pitched up to help. And that spirit of wanting to help those and contribute and volunteer is still very much there. So thinking about how we work with our volunteer networks and tap into that, but also thinking about how we work with our patient groups and their representation. If we're doing a drive on a piece of work, we're trying to do some healthy living work, let's get involved with our patient participation group. Let's involve the people that we're doing this for and work really collaboratively. So we're certainly beginning to think outside the box in that it's not just general practice, but how do we work with our local collaborators around it? And I think community pharmacy is a massive part of that, as well, because we talk about right care, right place, right time. Well, actually, if you've got a patient who's waiting to see a GP for the management of hay fever, they could be seen over the counter in a couple of minutes and managed appropriately in that setting. So making sure that patients get the high level of care wherever's best and easiest for them to access, and then seeing the right professional at the right time, as well.
- Yeah, and that's another really interesting area, 'cause historically, primary care and community pharmacy haven't always had a fantastic relationship. How are you interacting with community pharmacy now, and how is that relationship evolving?
- So certainly there's commissioning tools and structures, which allow us to work a lot closer with community pharmacy. So PCNs are incentivized to send patients into community pharmacy who could be treated there. So say for example, you've got someone with hay fever calls up the GP practice and said, "I need to speak to a doctor; I've got terrible hay fever." That practice might be able to navigate that patient into being seen by community pharmacist quicker than they would be seen by a GP. And then, if they can be treated over the counter, fantastic. The pharmacy can sort that problem out in a timely and a safe way. And if there are red flags there, the community pharmacy can identify them, have a consultation, begin to work the patient up, send those notes back to the GP practice so that where the doctor does see that patient, they've actually got a bit of a case history already. They know what red flags they're looking out for. They know what the management plan might be. So that's one way that community pharmacy is beginning to interface, and that's really growing within local NHS systems. Although it's nationally commissioned, those pathways have to be agreed locally. And that comes off the back of community pharmacy being integrated into 111 services, as well. So 111 now directly refers patients into community pharmacies who could be seen there both for emergency supplies of meds, as well as for the management of minor acute illness. The other big contractual mechanism is around hypertension case finding. So we know that there are a vast amount of people walking around with undiagnosed high blood pressure, hypertension within the UK. It's one of the incentives for the PCNs around their IIF, that they have to do some case finding work and making sure their patients who do have elevated blood pressures are well managed, and that's come out at the same time that community pharmacy has the hypertension case finding service. So actually, participating pharmacies who've signed up for this national service can identify patients who are at risk of having high blood pressure. So patients over certain ages or with certain family histories take their blood pressure in the pharmacy. If it is elevated, they can give the ambulatory monitoring. They come back, they send those data off to the GP practice, who can then have a full data set, appropriately manage the patient. And then, when that patient picks up their first prescription from the community pharmacy, their offered the new medicine service where the pharmacy supports that person in terms of getting to grips with their new medicine and looking out for any side effects, what to look for, what to be worried about, and what not to be worried about. So there are more and more services available for community pharmacy to deliver, which adds value into the primary care system. I think how they're linked up isn't quite there yet and it is an evolving picture. It's a local evolution, as well. So some places have really good pathways and relationships. Other places might only be thinking about one service or maybe just taking baby steps. But I think as time goes on, there will be a bigger service demand for community pharmacy to help support primary care.
- Yeah, and you've kind of teamed me up nicely for a follow-up question, though. I was kind of thinking about in terms of that, 'cause it sounds like there's really functional areas in which you are working, what are the practical bits that are required to make that a smooth transition for a patient so they're either referred from you to the community pharmacy or vice versa?
- So you have to have good working relationships, good professional working relationships. So that ability to be able to pick up the phone, know who's on the end of it, have really smooth processes and access between your different settings of care, that's really important. And that goes right to the very base level around prescription processing, as well. It's the stuff which will clog up our prescription cards, it will clog up our dispenses community pharmacy around. If there's a problem with a prescription, you've got to wait half a day or a day for it to be resolved. That throws a spanner in the works in terms of how work moves through those organisations. So having excellent relationships between those two organisations is really important, having open communications. There may be an exercise that's done around team building. I know, certainly, when we were setting a few services up when I was new in role, the first thing we did was we just got together and had a Chinese. We talked about a few of the services that we could both offer and where we tap into one another, and we just got to know each other's names. And that was probably one of the most valuable interactions that we've had, because now you pick up the phone, you know who's on the end of it. You can have a really... Those barriers in terms of access and formality drop away. So that's really important. And I think everything else follows. If you've got good working relationships, you can begin to say, actually, I trust this person to do X, I trust this person to do Y. You allow safe spaces for people to talk about their competence and what they're happy to do and not to do in a grown-up and honest manner. And then, you can begin to evolve those local pathways. So if you've got a patient who rocks up into community pharmacy, actually, they've got some red flags, they need to be seen on the day, how do you empower the pharmacy to say, "Actually, I need to contact the GP to get you in on the day"? Versus they have these red flags, but then they have to go through a tortuous route to get patients into their GP practice. And vice versa, as well, is that confidence that you want your primary care teams to have in saying, "I'm going to put a note on your prescription saying actually you would benefit from a new medicine service intervention." The confidence that that will then happen in the pharmacy that you're referring that patient into.
- Yeah, and that's a great illustration of how real sustainable change is actually achieved. And I suppose one of my questions that was going to be around the integrated pharmacy and medicines optimization, the IPMO guidance or framework, which it kind of lays out ways of working for the future. Historically in the NHS, there's always been a gap between policy and practice. So can you just expand a little bit on how influential kind of the policy is and how much of it is local working and kind of where they might meet in the middle?
- So in terms of the IPMO, often, ICSs will have a working route where they have a cross-stakeholder representation, and some systems are looking at recruiting into their ICS a chief pharmacist role for the system, as well as also having a chief community or not chief, but a community pharmacy lead role within that system, as well. So those are real key roles which will be developing. In terms of the strategy, in the kindest way possible, sometimes the people in these meetings are that those same faces who might be recycled through various NHS structure shuffles, but they're real valuable in which decisions can be made and stakeholders can be brought together. So as part of those working groups, you would want representation from primary care community, secondary care, your CCG , meds-optimization, and new ICS, or what were STP teams to think about dow did things work differently in that system. And if you've got an innovative thinker or a strategic leader leading that process, then that's a really good place where things can work differently across local systems and real change can begin to happen at a local policy level. So I think a lot of local systems will have those working groups, will be beginning to have the conversation around them. Where different people are will vary one place to another, but it's one definitely to watch.
- Yeah, thank you. Just coming back briefly to the role of the clinical pharmacist, you talked there a lot about the context and some of the particular things you're doing, what other biggest challenges that you face as clinical pharmacists?
- Workforce, absolutely, workforce and development I think are the two big ones. So there is a squeeze on the pharmacy workforce in general. So the way that PCNs were incepted were that there was this massive new drive around recruiting pharmacists into primary care. Very early on, the conception was that a lot of these professionals would come from secondary care, would come from hospital. That goes right down to the nomenclature and the naming of the roles. So clinical pharmacists was brought into primary care. So they don't have parity and equity with those hospital clinical pharmacy roles. So it's looking from the other end of the telescope. Whereas in actuality, what's happened is a lot of community pharmacies have left community practice to come and work in primary care, in primary care networks or GP practices. And what that does is we've, certainly in the Southwest where our, for me in Plymouth and East Cornwall, our nearest school of pharmacy is over, I was going to say over a hundred miles away. I think it is something like that. It's certainly over a two-hour drive to Bath, which is our nearest pharmacy school. So there's already local pressures in terms of where our new pharmacists qualify from and come from in getting them to come down to the Southwest. And we've got this added pressure of a lot new roles in the pharmacy labour market, but not a lot of new professionals. And what that does it increases the pressure on community pharmacy. We see more pharmacy closures or higher locum rates, which make businesses more difficult to operate when actually those businesses were a core part of supporting us through the pandemic. They very much kept the doors open and the lights on. So that is one: workforce definitely. And part of that is development, as well. So lots of new pharmacists coming into these roles, lots of pharmacists coming into these roles who aren't prescribers, as well. So I had the relative luxury of starting my work in a Primary Care Network as having experience with primary care and being a prescriber. Whereas a lot of pharmacists were coming in with no experience of primary care at all, no experience of how to work in an NVT setting or to work in the GP practice, but also having to be enrolled on a postgraduate course through our postgraduate education provider nationally so not higher education institutes, and then going out and getting a prescribing qualification. That's another gap that may drop away in time, because in a couple of years time, all new pharmacists in the register will be independent prescribers at the point of registration. But for the moment, there is a skills gap, and there's also a bit around clinical assessment. So when I qualified almost 10 years ago now, I came out of university being told and thinking that I was a scientist. Whereas now very much the new pharmacists come out will think of themselves as clinicians. And that is a big shift in mindset in terms of what we do as professionals. So a big piece around workforce resilience and a big piece around development. And then, there's the other point around we've got an ageing population. We've got a lot more comorbidity. We were until very recently living a lot longer than we ever have done before. So we've got a lot more people who are more complex and there's more work rocks up into secondary care. More complex work trickles down into primary care, as well. So how do we manage more complex caseloads in primary care with a workforce which is still evolving essentially? We've got some really, really competent clinical pharmacists out there, but also some who will be at the beginning of their journey.
- Yeah, and again, a few years ago, I remember those conversations about, well, if we do get a pharmacist into practise, who's going to supervise them? How do we know that they're a able to do what we're asking of them and also to help them develop? So in terms of that piece, obviously, your role within your PCN is providing that supervision. So you're obviously in a really good place. Maybe not every PCNs got that. As a, I'm going to use the word profession, clinical pharmacists in primary care, is there wider support? Is there a structured development programme, or is it a case of your plonked in a practice, and if you've got a supervisor, great, if you haven't then good luck and that kind of approach?
- Yeah, absolutely, and I think that was some of those anecdotes and horror stories from the early wave of pharmacists and primary care is that you've got someone shut away in a broom cupboard. No one really knows what they're doing, and no one knows what their competencies are. For me, education development is what gets me out of bed in the morning. I love making sure my team is supported. And we have an open learning culture and a culture of compassionate leadership and helping everyone to develop. It's written into the PCN contract around ensuring. It's very black and white around the supervision that clinical pharmacists should get. So absolutely, you need to come in and have a certain educational level or be on a pathway to achieve that. And the main pathway is through CPPE, which is the Centre for Pharmacy Postgraduate Education, available I think through the University of Manchester support organisation. It's a national pathway, 18 months, and it includes a prescribing qualification, as well. That's to bring everyone up to the same level and ensure the same level of service delivery across those different care settings within this new role. But within practice, these additional roles are reimbursed entirely through central government funding. So attached to them are the strings around supervision. So each pharmacist must have a session of clinical supervision by senior clinical pharmacists within that organisation. And each senior pharmacist must have a session of supervision by a GP within that network. I'm very black and white with it, too. I really think that if you've got a fantastic colleague who's being funded by the NHS to work in your organisation, there's no two ways about it, you have to provide them with clinical supervision. I think often when people fall down around it is that, actually, it's adult learning. And supervision isn't someone sitting in a room watching what you're doing and literally supervising you. It might be case studies. It might be small group facilitation. It might be actually identifying learning needs and working at the training session or a learning session together. And a lot of general practices are used to doing this with our F2s, our F1s, and our ST specialist , as well, as they're coming through in their GP practice training. So you can take the pharmacist into that. There are already existing opportunities for pharmacists to join in and other supervision that happens, but it's something that I'm really keen to ensure that all of our team get. And that would, that's the kind of thing. If I heard that it was happening in a network that would really make me irritated that that wasn't happening, because it's a core part of the role and people should be supported to have that supervision.
- Yeah, fantastic, and is there a kind of a outside of your own network as it were or locality is there now a sort of national or even kind of regional sense of community among clinical pharmacists, or are you kind of working in isolation within your own organisations?
- So I think definitely there are growing local communities. So we have like WhatsApp and telegram groups. I know in some, like in our PCN, we've got a group while we're all in, and we chat about staff or our clinical queries, as well as what we're doing on the weekends. There's a real lovely feel to it. But there's also wider regional groups, as well. The PCPA, the Primary Care Pharmacy Association, have a national telegram group. And if you are connected with pharmacy in any what way you don't have to be a PCPA member, you can join that national group. There are thousands of people in there. We talk and they talk about clinical queries about working in general practice around how to manage certain patients' conditions. Obviously, it's all anonymized, but it's working at case studies together. And we can really tap into some excellent national experts who are in that group, as well, and everyone will chip in and give advice. And so there are lots of networks out there. There are other supports such as through the Royal Pharmaceutical Society. There are local practice networks, as well. So there are communities out there I think in terms of the educational needs. And in terms of developing up a really supported training and development package, though, that's something which needs to be very grassroots, depending on the confidence of the pharmacist that you've got in your network and what they need.
- A lot of our audience work in the industry, and they're always asking what they can do to support with development and networking all those sorts of things. Are there any things for you that jump out as opportunities for support for clinical pharmacists?
- So definitely there are needs around training. So when you've got training delivered by a local expert, you can develop a relationship with and potentially know how to refer someone into secondary care or even being given that permission as it was to be able to send someone an email about a case study, and you think which supports learning and develops local relationships with secondary care. That's really valuable to primary care pharmacist. It has to be relevant, and it has to be applicable to the role and to the learning needs of that cohort of who are going to get involved with it, as well. Product information is always useful, especially with regards to prescribing, as well as links in if you've got someone who you know has an interest or a specialism linking in with other larger pieces of training that they can access, as well. But bearing in mind that the CPP training that the majority of clinical pharmacists will do who've not had experience in primary care, it's a lot of work, so it's 18 months. It's a lot of work in work. It's a lot of work in terms of hours outside of work, as well. So it might be that, actually, if someone's on that pathway, they might not have a lot of bandwidth to get involved with lots of different training courses. That's always helpful. And also just being there around. I think sometimes networks don't pick up on sponsorship opportunities, as well. If you're going to get together with the community pharmacies actually, have a chat with your local pharma rep, see if they'll come in, and five minutes at the time, they may provide you with dinner, which is always nice.
- Yeah, thank you, so I'm going to get stuck into some controversial questions potentially now, all the big hitters. So historically in primary care, there's always been a conversation about perverse incentives for prescribing in terms of going forward within the ICS structure. Obviously, there's lots of question marks about APCs where formulas are going to sit, how all of those things are going to be managed. What level of autonomy do you think PCNs might get in decisions around prescribing?
- Really interesting, and I think that you can get different perceptions on this already. I would look at the way the wind's blowing. So in terms of where the DES and the network contracting for PCNs are, a key part of that structure of medication review DES is medicine's optimization. That's a function we normally see at an ICS or a then CCG level. It's lying in the spec with not a lot to do at the moment. It's just there as something that you do as part of SMRs. So what that implies is that's there and it might grow. So there might be more meds optimization incentives that grow their networks. If you look at the IIF in terms of the different indicators that are out there, there's lots around quality improvement and actually a mimics really closely piece of work done by the University of Nottingham some years ago that we used as a network before these prescribing indicators came out in terms of quality improvement. That's also meds optimization, but thinking about where budgets could go, it makes sense for on my personal view, is that it makes sense to have formularies held at a system level because it aligns to your acute centres. It aligns to your secondary care providers, as well as your primary care providers. And you can get them all in a room together to align in terms of what works best for the system. But in terms of capitation and responsibility, it might very well be that PCN's responsible for drug budgets in times come, but who knows.
- Yeah, okay, fantastic. I think that's probably about as far as we can go with that for now. Just following on from that thinking about kind of that integrated piece and there's going to be a system budget for everything, and everything's got to come out of there. Lots of conversations at the moment about, you've talked about yourself, sort of deprescribing and looking at other ways to manage certain conditions. At the same time, there's a whole load of pharmacological treatments out there in increasing number that do very good things. So do you see pharmacy as potentially a winner or loser in the battle for integrated funding?
- So I guess there's two. When we say pharmacy that can mean community pharmacy, the brick and mortar, or it can mean the pharmacy workforce. I think when it comes to a workforce approach, pharmacists, absolutely, the role is evolving. We love to use the phrase in the NHS. The profession is at a crossroads, or we are at a crossroads. And I think pharmacy's been at a crossroads for the last, you know, every year for the last 10 years, but it is really changing very, very fast in the last four or five years with the inception of PCNs. So big win there in terms of the recognition of the competence, the capability, and the worth of pharmacists to the wider NHS system, absolutely. I think in terms of where the community pharmacy contract is in terms of bricks and mortar really, really hard market out there at the moment. So it's difficult for people to keep the lights on. The pharmacy contract was once many years ago something which could be something that you could provide a great service to your patients with, as well as being able to run it as a business. Whereas now, even the operating costs are difficult to cover under just running an NHS contract through a community pharmacy. There's a massive squeeze in terms of dispensing versus services. So I think very much the direction of travel for community pharmacy is towards a service led model, as opposed to the traditional dispensing function model. But we shouldn't lose sight of that either. That actually it's an important function. People need their medicines. And I think there's a lot to be said for brick and mortar pharmacies to have a presence in their local communities, versus these nebulous online organisations where patients can't access pharmacists or not necessarily get the care that they need or the access that they have through their community pharmacies where they can walk through the front door anytime that they're open and usually get seen in a couple of minutes. So I think times are hard in community pharmacy, but in terms of the pharmacy profession in primary care, lots of opportunity.
- And in terms of the medicines themselves, I know that's a vast, vast array of different things. Do you foresee any particular trends in more prescribing, less prescribing? Will there be certain things that go up and certain things that come down?
- So I think we know that there's a lot of inappropriate prescribing that happens in our system at the moment. There's no two ways about it. And I don't think anyone wants someone to be on a medicine they can be without. Yet to meet a patient who is really glad to be on 10 or 15 different types of medicines. Everyone always says, "I'm on so many bloody medicines. Can I drop one or what can we do about it? Do I need all of them?" And actually, it's looking into that need. So I think as a nation, we have a very westernised medicalized view of treatment. So we want a tablet if we've got ailment. Whereas actually, we know in certain things like chronic pain that those opioids cannot... After three months, pain is no longer a good indicator of tissue health. And after three months, those opioid based medications can sensitise people to pain. They can make pain worse in terms of the host of risks, as well. So there is a big trend around good pain management at the moment and making sure patients have the relief they need whilst minimising the risk of harm from medicines. There is a trend around looking at patients who are very frail patients who are permanently resident in care homes and also are meds at high risk of addiction. So I think certainly patients who are maintained on those, there is a national push to decrease those types of medicines prescribed more widely in terms of the risks versus the benefits to our patients. But that being said, there's lots of new technologies coming out. I think in terms of the industry wider is that there's a lot of bits coming out about the scaffolding around medicine. So packages of care, which is really exciting and innovative, but I think especially in the elderly population, we're probably thinking about how do we work smarter and providing the best benefit for patients whilst minimising the risks.
- Could you just expand a little bit. You talked about the packages of care, the scaffolding element. Could you just expand a little bit on what's exciting about that to you?
- So I think things like near patient testing and digitalization is really exciting. I mean, there's nothing you want more as a clinician for a patient to be able to have their own data and be able to monitor themselves and then present the data to you in a way that you don't have to have a thousand logins to a thousand different systems. So say, for example, you've got someone who's living with diabetes and they've got a system which, they've got a really good log of their blood sugars and what they're doing in certain times. They've got a diary with it, as well, and they can give you those data at the point of consultation and you don't have to go looking for it. You can actually get a really good insight to what they're doing and how they're living and how you can help them with the medicines they're prescribed to provide the best value to them, as opposed to the patient who think you're providing the value to versus those handful of bloods that you might have from them. So I think there is a big around technology and a lot around access as well and how we use clinicians differently and how we can keep clinicians in the workforce working remotely or providing remote care into patients, as well. So lots of space for innovation, but in that same space, lots of space for repetition, as well. So we don't want a thousand tools that are already shiny and do very specific things. A handful of tools that are really effective, that're fantastic.
- Yeah, brilliant, thank you, Tom. We're getting towards time. We've got a few minutes left. One of the other questions I wanted to ask you. There's been a couple of high profile national initiatives, national procurements around specific medicines for delivering primary care. Anticoagulants is an obvious example where there's been a drive to increase the uptake of a specific medicine through particular incentivizations. There's different schools of thought around whether that's a good thing or a bad thing and particularly around whether it's the right thing to be doing when there's capacity challenges. How are those kind of initiatives, regardless of what the specific products are, how are those kind of initiatives of, "Here's a national guidance, national incentive, go out and make these changes," how is that actually received in practise?
- So I think to refer to use that example as a case study and a space where industry can support with there's often funding available for their parties to support with that. So we've had remote support with providing consultations to patients who are on certain types of anticoagulants and need review. And then, if they need to be changed, they can be changed to the national preferred option within that space. I think ultimately we work in a, my personal thoughts on it is we work in a social health system at the end of the day. There's something that needs to be provided at a system level, and we're being incentivized to do it. As long as it's safe for our patients, why wouldn't we engage with that. And being on the other end of the spectrum, being mercernary about it, if you're thinking about the revenue you can pull in around some of that, there are lots of levers such as there might be a rebate scheme or there might be additional support to deliver that. I think in terms of those types of incentives, they're really easy to deliver when you've got capacity or options to provide capacity. The difficulty is when you get more localised prescribing incentives, and this is, again, just my personal opinion around branded generics, which makes supply difficult and often creates a lot more headache than the savings that you generate. So sometimes, we know best practise ideally is to prescribe generically where safe, and it's not appropriate for a sway that medicines, especially when you get to modified release of specialist therapies. But when you are doing, you are suggesting to primary care clinicians to describe a brand of a drug, because it gives a small cost saving at a local system level to that meds optimization team. But then, you find that actually that particular brand of generic goes out of stock a couple of weeks later, you've then got a host of patients who need to be switched back onto generic, and you create additional workload. That's the real clincher where actually we're not delivering any added value either to the system or to the patient, or we're not doing anything about environmental sustainability. We're doing it almost for a very localised cost saving, which isn't realised by the practise. It's by the CCG. And then, it causes a lot of work that washes back up general practise. That's the real difficulty, as opposed to some of the bigger pieces of work we can do to make sure our patients have the best care, but also as a national system we're working efficiently.
- Yeah, and in terms of those local schemes, do you think those might continue be constructed in different ways? I mean, you mentioned sustainability there, which is increasingly prominent in the NHS. Do you think local decisions about these are the things that matter to us might change the way in which local prescribing initiatives are designed?
- I think that there is a flaw around the some local prescribing initiatives, certainly when it comes to stuff like branded generics and in health, we're... It's almost a financial exercise, because the global envelope pharmacy funding isn't changing. It's reliant sometimes on geographical disparities between different counties that doesn't affect the overall tariff price. But I think certainly there are a lot more levers attached to things which do benefit the system. So such as sustainability, that's in the national priorities, but that's also seen in local incentives, as well, around those carbon waiting for things like inhalers prescribed in primary care. That's something that's aligned to local priorities. And that's really helpful when all the holds line up essentially.
- Great stuff, thanks, Tom. I've just got one question to finish in on really, which is around the role of industry. And have you got one takeaway for the audience about what the key is for them to successful engagement with you and your peers?
- I'd say build a really good relationship. The worst thing that I... The biggest barrier and the biggest not annoyance, almost heart-drop moment I get is when I'm in the middle of a really busy clinic, and then a message pops up saying, you've got a rep on the phone wants to have a chat. It's like I'm almost never going to say yes to that, because it's so busy, but I would love to build a relationship at an appropriate time. So if there are training events that are available or meetings run by local LPCs where there'll be lots of pharmacy representation or big webinars, attend, put a face to your name, get yourself out there, and build those local relationships. And then from there on in, you can start talking about innovative stuff, about do you want to pilot something in a PCN, or can you do a piece of work or support with something of the PCN has a priority. It boils back down to those personal relationships and what gives that person the confidence to lift the phone to you as a rep, essentially.
- Yeah, fantastic, thank you very much, Tom, for your time this afternoon. I know you're sweltering there. So hopefully, you'll be able to grab some air in a second. There's just enough time for me to announce a symposium that we are running in London on the 29th of September, looking at your commercial planning for 2023, bringing together NHS experts from across our network to explore the people, payments, and pathways, the three main areas of concern for your own plans for next year. To get limited, keep an eye out for an email after this event. There will be an early bird discount. So getting early for one of those, and hopefully, we will see you there. On July the 22nd for our next webinar, I'll be doing a bit of a review of the first few weeks of formal ICSs with some of our associates to look at what's working, what's not, and dissect what lies ahead in the short-term. So, Tom, thanks again for joining me today. Go and grab some air. Thank you, everyone else, for listening and watching, and we'll see you next time. Thank you very much.