INTRODUCTION
It is widely acknowledged that there is a workload crisis in UK general practice. In addition to the impact of population growth and an increase in the number of older people with complex health needs, GPs have also taken on a considerable amount of work previously undertaken in secondary care. The result has been a 16% increase in overall GP workload, over a 7-year period up to 2014, according to a recent large-scale English study.1 So far, there is little sign that the promised increase in resource heralded in the 5-year General Practice Forward View is making a difference on the front line.2
INVESTING IN PHARMACISTS
One approach to tackling the workload crisis is to draw upon the skills of other healthcare professionals, particularly those who are able to prescribe, with pharmacists being one example. In this context, the investment from NHS England in expanding the number of pharmacists working in general practices is welcome. In addition to the pilot wave investment of £31 million for the first recruitment wave of 490,3 there is a commitment to invest an additional £100 million to part-fund 1500 pharmacists to work in English general practices over the next 3–4 years.4
There is a reasonable body of evidence confirming the benefits that pharmacists can bring by working in general practices. For example, pharmacists working in primary care can help with chronic disease management, and there is evidence that they can be effective for a wide variety of conditions5–7 They can also help more broadly with medicines optimisation,5 and can work with GPs to reduce hazardous prescribing.8
From my experience of working with a practice-based pharmacist there are many other ways in which they can ease the burden on GPs, including taking on difficult prescribing challenges (titrating up or withdrawing medicines), undertaking complex medication reviews, taking on medicines reconciliation for patients discharged from hospital, and negotiating with patients about medicines changes for increased effectiveness and cost control.
READY AND WILLING
Also, as highlighted in this edition of the BJGP, pharmacists are enthusiastic about their new roles in general practice.9 In a qualitative study in South West England, pharmacists were interviewed before and after a training programme aimed at equipping them for working in general practice. While recognising their ongoing training needs, and the challenges and uncertainties around their new roles, the pharmacists were willing to take some of the load off GPs.
COVERING THE COSTS
So, what is not to like about this expansion of pharmacists in English general practice? The main problem is the funding model. The NHS England contribution to the costs of recruitment and employment is tapered from 60% in year one to 20% in year three.4 This means that general practices which have taken on a pharmacist are now having to give serious consideration to the opportunity costs of continuing to employ them in the longer term.
When faced with 80% of the annual salary of a pharmacist, GPs in a fully staffed general practice (or federation of practices) will be asking whether any benefits of the pharmacist on their workload are sufficient for them to be prepared to reduce their drawings. In practices with staff shortages they will be asking whether they might be better off investing in more GP sessions or a full-time nurse.
The problem is that, however good pharmacists are, it is unlikely that they will reduce GP workload in the way that an additional GP or nurse would. Also, as far as I am aware, there is little or no evidence available on the impact of practice-based pharmacists on GP workload to enable GPs to make a fully informed decision on this issue.
WHO SHOULD PAY?
Therefore, I worry that unless the funding formula is changed we may find that this admirable scheme to expand the pharmacy workforce in general practice may run into the sand. I suspect that many general practices will be prepared to make a financial contribution to employing pharmacists, particularly where they genuinely reduce GP workload. However, previous studies suggest that the majority of the impact of practice-based pharmacists will be on quality and safety,5 rather than on GP workload, and it is reasonable to ask whether GPs or the government should be paying for this. If NHS England is serious about putting more resources into general practice and easing the burden on GPs, a more generous approach is needed to the ongoing funding of practice-based pharmacists.
Provenance
Freely submitted; not externally peer reviewed.
Competing interests
The author is a co-investigator on a national evaluation of pharmacists in general practices.
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