Skip to content

The art of the possible – NHS Pharmacy First Plus

Sometimes you meet someone who epitomizes the art of the possible in any walk of life. Pharmacist, Sandra Robertson is one such person. She has taken the ART (advice, referral or treatment) of community pharmacy practice in Scotland quietly to new levels.

I sat down for a chat with her to get a feel for how she continues to lead from the front when delivering the NHS Scottish Pharmacy First service.

Sandra, can you introduce yourself and share your career journey so far?

“I studied at The Robert Gordon University and explored various aspects of pharmacy throughout my career so far. I completed my preregistration year in hospital and industry before entering community pharmacy. I have worked for both small and large pharmacy chains. In addition to community pharmacy, I have also worked in GP practices when pharmacists’ roles were still evolving. While I primarily focused on community pharmacy, I gained valuable experience in practice.

“I have been involved in respiratory care in GP practices for about 20 years, initially managing chronic conditions and conducting COPD reviews. To summarize, I spent five years working in primary care clinics, which was a significant career boost. I also worked in a GP practice adjacent to my pharmacy, handling a wide range of issues, including urinary tract infections, chest infections, asthma, and COPD. Additionally, I handled skin conditions, minor illnesses, and hypertension.

“Many of the skills I developed in primary care are transferable to community pharmacy. However, I briefly ventured into pharmacotherapy due to certain circumstances, but my true calling is in community pharmacy. I’m fortunate to have double pharmacist cover, allowing me to do a lot of prescribing.

“My experience has been somewhat unconventional. I gained extensive expertise in asthma and COPD during my time in primary care. It’s a bit frustrating to acquire specialized skills and not have the opportunity to use them fully in community pharmacy. We’re the only healthcare professionals who acquire new skills and are limited in their application. However, things have improved with the NHS Pharmacy First Plus service, but there’s still work to be done.

Sandra was one of the early pioneers in both independent and supplementary prescribing in Scotland a number of years ago. Reflecting on this it struck me that many working in community pharmacy elsewhere in the UK may not fully grasp how far we’ve come north of the border.

To add context to her career story and to help readers understand how much we have moved forward I asked Sandra to describe what a typical day looks like for her in her role as an independent prescriber working in a community pharmacy in Scotland. She describes a typical day which involves two pharmacists working to support the delivery of the NHS Pharmacy First Plus Service.

“Today was one of those days. We are fortunate to have two skilled dispensary team members, one as an accuracy-checking technician and the other as a checking dispenser. Utilising their skills is essential for providing top-notch pharmacy services like NHS Pharmacy First Plus. We ensure that we complete the clinical checks efficiently, allowing us to handle interruptions seamlessly.

“When I arrive in the morning, either myself or Louise (pharmacist colleague) will perform the clinical check on the prescriptions. We rotate roles to keep things interesting. I usually take on the checking role when I’m not consulting because it’s easier to step away from. Avoiding interruptions during labelling or preparation. This approach ensures a smooth workflow. It helps maintain the flow.

“Our well-trained staff at the front counter handle the Pharmacy First consultations for minor issues. When they detect a more serious concern, they alert me. For example, if someone comes in seeking cough medicine and has been coughing for several weeks, they’ll call me. Often, patients are surprised that their seemingly minor issue might have underlying problems.

“Just today, someone came in for a cough, and it turned out they had a chest infection, eczema, and a history of asthma. This depth of knowledge can be beneficial, even though technically chronic conditions aren’t covered by the NHS Pharmacy First Plus service at the moment.”

Our conversation turned to leadership. I put it to Sandra that the direction set by the profession’s leadership plays a significant role, and once they establish a path, everything else to some extent falls into place.

In Scotland we have had Prescription for Excellence, Achieving for Excellence in Pharmaceutical Care, and before that, The Right Medicine. Once the policy document has been digested the evolution of the contract begins. In recent years this evolution has rumbled forward.

In the next few years, there is an expectation that every pharmacist qualifying will qualify as an independent prescriber. It seems like things are finally changing.

It’s an interesting point for policymakers because many pharmacists with prescribing skills and experience could argue that they are underutilized.

To put a positive spin on the conversation I asked Sandra to consider the ideal scenario for pharmacists, especially those newly qualified ones who will become independent prescribers or perhaps youngsters who are considering a career in pharmacy. I asked her in this ideal scenario, what kind of support and resources would be necessary to step forward beyond the current NHS Pharmacy First Plus service and effectively run chronic disease clinics or manage chronic disease activity in a community pharmacy. I wondered if Sandra thought this would involve comprehensive patient management, or if would it focus on specific areas, such as identifying high-risk individuals.

“When it comes to chronic disease management, we don’t intend to replace nurses or GPs in handling conditions like hypertension or diabetes. That’s not our goal at all. What I believe is necessary is proper training, and beyond that, hands-on experience is crucial. Many other healthcare professions provide more practical experience than pharmacy. For instance, they often work alongside specialists or in various clinical settings.

“Regarding community pharmacy, I see it as an extension of healthcare services. For example, a patient may walk in with a chronic cough that’s worsened over time, and they haven’t received a diagnosis. Maybe they’ve had a past respiratory infection. In such cases, it’s about upskilling pharmacists to recognize the early signs and symptoms. It’s not about taking over the role of a GP. It’s about identifying that a chronic smoker with a persistent cough might need a chest examination or further evaluation.

“It’s about recognizing the early signs and symptoms. One issue currently hindering this is the lack of access to GP computer systems. However, I believe this is a political issue because the necessary technology exists. The Clinical Pharmacist Managed Services (CPMS) team, for instance, can access these systems. I’ve even accessed them from home. I can’t understand why we can’t have direct access.

“In fact, I believe most pharmacists would agree that having direct read-write access to patient records is essential. Working in general practice gives you access to a vast amount of information, which, although controlled to an extent, provides a comprehensive view. However, community pharmacists have access to different data, and people often underestimate how well we get to know our patients.”

“I’ve dealt with a variety of cases in community pharmacy as an independent prescriber, ranging from straightforward ones to more challenging situations. For example, there was a patient who wasn’t from the local area and was on holiday. Handling such cases can be trickier because arranging an appointment with a local GP for temporary residents is not always straightforward. In one case, I had a patient between chemotherapy cycles who potentially had a urinary tract infection. Their condition worsened dramatically from the time they arrived at the pharmacy to when they reached the counter. In such situations, I tend to lay out the facts, explain the possible conditions, and discuss the available options, sometimes including calling an ambulance for immediate care.

“Supervision as part of the training process and ongoing oversight is very important. We’re quite lucky with a double pharmacist cover. I would honestly say that would be very much the exception rather than the rule. After the period of learning and practice, there’s no real student supervision. For me, if it’s something I’m unsure of I refer someone to the duty doctor. I’ll quite often ask the pharmacy at the health centre to give me feedback for my own learning. As much as possible I try to close the loop for my own learning so that means that I’ve seen the person, I’ve done the history and I’ve passed it on.

I wanted to find out how Sandra felt community pharmacy practice might progress in Scotland in the coming years. What’s the current vision?

“In the next ten years, I believe pharmacists will have access to GP computers, which will make us more integrated into the healthcare team. As more people become aware of what we can do, including healthcare professionals, we’ll become more skilled in managing minor ailments and potentially chronic conditions. However, it’s important to remember that not everyone is on board with these extended roles, so our role should also involve bringing everyone in the profession up to speed. It’s about consolidation more than an ego trip for me. If we don’t consolidate, we’ll remain outliers, and the goal is for people to say, ‘Go to any pharmacy; they can help with this.’”

“Thinking of the future and considering examinations there is something I’d like to mention, especially for new prescribers who might be a bit nervous. In my earlier days as a pharmacist a number of years ago, we didn’t interact physically with patients. We stayed behind the counter, and we were not sure of our role. But now, suddenly, everything is hands-on. When I began prescribing more for minor illnesses, the thing that caused me some concern was that I hadn’t been taught examination skills. The local doctor did provide me with a crash course, but what’s important to remember is that while learning examination skills is valuable, they don’t replace the importance of taking a thorough patient history, in my opinion.”

Speaking to Sandra was as fascinating as ever. By her own admission she is not really interested in the politics of pharmacy but what she has to say is important because she is walking the walk within the parameters of the NHS Pharmacy First Plus service.

I have done a few locum shifts in the pharmacy that she works in and I can confirm that the people she serves absolutely love and appreciate the service that she and her team deliver.

I took away quite a few reflections from my conversation with her not least that it’s easy to critique. It’s also crucial to engage in professional conversations about legality, risk, scope of practice, and ultimately patient care. Sandra mentioned earlier that she sometimes feels overwhelmed due to the success of the service, especially on weekends but overall she really enjoys the role.

Like any new service rolled out at scale there is quite a long way to go so that all community pharmacists have the opportunity to pursue this more interesting and rewarding career path. Obvious considerations for the profession that come to mind are training, supervision, greater integration into local healthcare teams and of course proper read/write access to the patient record.

NHS Pharmacy First Plus in Scotland should probably be seen as a startup within an existing system. Given the excellent start that Sandra and others have made it would be great if the momentum kept growing.

Sandra Robertson (left) and Louise Still (right)