Johnathan Laird MRPharmS(IP)
Like so many others recently I took the leap to the promised land of general practice. I have not really written about my experience of working in there largely because until now (2 years in) I had my head down finding my feet in this devilishly complex yet interesting role.
Do I love it? Hell yes but I still want to own a community pharmacy someday. It’s where I feel most professionally at home.
I thought it might be interesting to follow my blog on community pharmacy prescribing by drawing some comparisons with my experience so far working as a prescribing pharmacist in general practice.
The first thing I have to mention is the culture. The standards of practise are extremely high and the issues dealt with are complex but there is no emphasis on targets. Rather a collective team effort to get the work done. As many reading this will fully understand this is completely at odds with working in many areas of community pharmacy.
And this is when my life changed. This bit is important. For the first time since qualifying as a pharmacist, I no longer felt I had to apologise for delivering excellent pharmaceutical care. On a personal level, the psychological impact of no longer working in the hamster wheel of community pharmacy management took about a year to resolve. And in that time the practice team made me feel welcome but they also took myself and my other two pharmacist colleagues under their wing.
I began prescribing in this role from day one. It was expected and that was fine. My day is split in two. Morning involves hospital discharges, medication reviews and supporting the non-clinical team to resolve queries swiftly. My excellent practice manager had the foresight to plonk us pharmacists right in the centre of the admin area. We remain at the heart of all goings-on in that space and are on hand to support as necessary.
The detail about the environment is important because I went from an isolated pressurised situation where I was trying to do the odd bit of largely piecemeal prescribing to being at the centre of operations in a reasonably large multidisciplinary team. I do some prescribing in the morning to help these processes run smoothly but most of my prescribing activity happens in the afternoon.
The afternoons are my favourite part of the job. I run an ‘on the day’ clinic. Common clinical conditions are triaged to me and off I go. The level of supervision here may be of interest to others. Each of the GP partners took a turn at sitting in and coaching me when I joined the practice. This support was weaned away. Now the GPs are on hand to back me up if needed. Two years in I thankfully need less help but I will often refer especially if I spot something potentially serious.
And that is an important point because without the basic validated levels of competence how would a newly qualified PIP know what they were spotting or missing?
Without this level of supervision, even the best PIP in the country will be risky in my view. It’s about having insight into what you are doing, the consequences of your actions and the impact of those actions on the patient now and into the future. I suspect my medical colleagues would agree and that view will most probably be formed based on hard-earned competence after time served through many years of training to become a GP.
The practice team didn’t stop there though with the support. I have regular clinical update training sessions with the partners. We have a regular pharmacist and more recently multidisciplinary meetings. We cover practical systems based topics but now we will bring a case along to the meeting where we share and reflect together on what we could have done better. We also have a regular scheduled meeting with the local community pharmacy teams.
On joining the practice, I went back to basics and completed the NES GP pharmacist foundation framework in year one. I have recently completed patient feedback and 360-degree feedback from my fellow team members in preparation for hopefully submitting my advanced stage 1 portfolio at Christmas. And you might be wondering why I went back to do foundation 10 years into being a pharmacist. This decision addresses my concern that some pharmacists feel that just because they have experience under their belt as a non-prescribing pharmacist this will transfer into competence as a prescriber.
It absolutely does not transfer. Working as a prescribing pharmacist is a different role from the traditional dispensing role and requires support similar to the intensity outlined above to gain the required skills.
So how do we make PIP practise safe as we develop many in this role?
Working as an independent pharmacist prescriber is a complex activity. I think the first cultural shift for pharmacists is to understand that you cannot take comfort in a standard operating procedure when engaged in prescribing activity. You can have protocols to guide what you are doing but at the end of the day as a PIP you will be exposed to a much more varied and nuanced type of risk. I often finish my clinics these days craving some certainty. As PIPs we often have to manage risk and make decisions based on thorough history taking and clinical assessment. In these instances it is critical to justify and document your thought process.
And that leads me to the next culture shock. Over the 8 years I worked in community pharmacy I had 1000’s of consultations of varying depth but I recorded none of them in a structured standardised way. Why? Basically, because there was no requirement to. I had feedback early on from a senior partner at work who questioned me when I said that a patient had exhibited ‘guarding’ when I examined their abdomen. The trouble was that at that point in my training I didn’t fully understand the importance of the language I used when writing in the patient record. In this case I had misinterpreted the word guarding and what I had actually observed during that examination was tenderness. The former could indicate an acute abdomen and therefore potentially that patient would have needed to be admitted. The skill of writing in the record is therefore complex and requires skill and precision to ensure medicolegal rigour. I have no idea how a pharmacist could self-teach this skill but this is what I see happening.
Clinical supervision by medical colleagues is critical to support the development of PIPs as they gain confidence. I have had 100’s of hours of supervision and feedback to help me progress to the juncture I find myself at today. This is yet another culture shock and I actually had to get used to others being interested in my development as a pharmacist. The practice I work at are a training practice for GPs so they are used to these processes but nevertheless the culture there is completely impressive and I am absolutely grateful for this. Within the bubble of supervision my GP colleagues manage the overall risk of the multidisciplinary team as we all progress. This allows them to retain control but continues to push us all forward. I would be very sceptical of the overall safety of any PIP who qualifies and then begins prescribing without medical supervision. I think the concept of community pharmacy training practices would be a good way to address this need but again I think we are some way off this.
The GPhC state that as a PIP you must work within your competence. My view in this area has hardened as I have gained experience. Whilst I’m not sure that every PIP needs to become an advanced clinical practitioner (ACP) I do feel that as a minimum they should build a portfolio of competence relevant to each area of prescribing practise that they are involved in. I would be nervous and sceptical about any situation that involves self-declaration of competence with no third-party involvement. Competence based portfolios must be signed off and validated by experienced medical prescribers at this stage. I think pharmacists will be capable in due course of doing this but at the moment the vast majority of PIPs are not ready for this level of responsibility.
I think PIPs need training on how their risk profile changes over time. We can learn from the aviation industry here. When you qualify you will be unconsciously incompetent in many areas. You are risky at that stage. As you gain confidence you will most likely get a fright or two and subsequently, you will take things slowly and become cautious. Time will pass and the brakes will come off again. At this secondary point approximately 1000 hours into practising as a prescriber I think you will likely become risky again. You need to ensure your indemnity insurance is watertight. Again medical supervision is essential to manage this risk and help you to gain insight into understanding it today and how it might develop over time.
I now own a business and therefore make professional decisions regularly about to what degree I engage commercially in the market. Pharmacist prescribing could be seen as getting your hands on the keys to the sweetie jar and you suddenly have the ability to give patients what they want. You are now a clinical decision maker. I have seen some business models where PIPs receive payment only if they prescribe an item. This presents an overt conflict of interest especially if prescribing and dispensing on the same premesis. I think the Scottish Electronic Minor Ailments Service (EMAS) is a much better commercial model to reimburse PIPs for managing patients. EMAS in Scotland is funded by the NHS and provides a payment structure within which the pharmacy owner receives payment based on the number of patients registered on the service in that community pharmacy. The aspect of this commercial structure that I like is that it actually creates an environment within which there is a disincentive to prescribe any medicines but doesn’t penalise if a prescription is required. Once your customers realise that you can prescribe a wide range of medicines, most notably antibiotics, you will be inundated. You need to think professionally how you will manage these expectations given the commercial pressure to make the business viable.
All PIPs should be supported to reflect on and audit their own practise. It is essential that this happens to identify PIPs as outliers and identify unusual or potentially risky practise. This concept is standard practise for our medical prescribing colleagues.
I was alarmed recently to learn that many PIPs practise in a range of settings without access to the full medical record. My view, based on my experience would be that prescribing without access to the full patient record should be the exception to the rule and not be the norm. There is so much relevant information in the patient record that could have a direct bearing on prescribing decisions. Blood results, previous diagnoses, actions in previous consultations, communication from third parties including consultants and allergies are just a few things that are essential pieces of information to ensure safe prescribing. I would need to be convinced that a PIP working full time without the patient record can do so safely. I would turn this around and ask why would you not want full access?
The above points are not exhaustive and there are more aspects to the practise of a PIP that are required to make it safe. I am not a jobsworth in fact I think for a pharmacist I am quite brave in terms of the risk I take on. But you can only demonstrate this courage if you understand the risk you are taking. And yes this is a sweeping statement but I do see a considerable lack of insight by some in our profession in terms of prescribing practise. Most concerningly I see this lack of insight at all levels of our profession including those professing to be our leaders.
I have questions around the ability of the GPhC to regulate in this area which is why I welcome the current consultation. I think other representative bodies really need to get ahead of this issue and do what they call ‘horizon scanning’ to support their members to prescribe safely.
My final thought on this topic is around what it means to be a pharmacist. I think we need to get back to championing the notion of professionalism. Without professionalism, we are simply painting by numbers. Independent prescribing provides a mechanism for pharmacists to eventually work autonomously and provide excellent care for patients. I actually see it as a lifeline for our profession to survive and thrive into the future and I would hope in years to come pharmacists will qualify as prescribers. I am completely optimistic about the future of our profession and I hope my concerns don’t put pharmacists off completing the qualification.
One of the highlights of my professional life was when I signed my first prescription. I got a glimpse of profound professional autonomy and I think it is this professional autonomy that we should aspire to.
If we choose not to take this step we will forever be followers not leaders in patient care.
