Ills, pills, and skills: developing the clinical skills of pharmacists in general practice

INTRODUCTION

The recent national pilot — ‘Clinical Pharmacists in General Practice’¹ — heralded in the General Practice Forward View, has enabled 500 pharmacists to potentially have patient-facing, practice-employed roles within general practice, with a further 1500 pharmacist roles planned by 2020.

This staff-bolstering scheme, along with new opportunities for other allied healthcare professionals in primary care, comes in response to current concerns about general practice workforce capacity, where modelling around staff recruitment, retention, and retirement have raised concerns about shortfalls in GP numbers.² Despite the optimistic assertions presented in the ‘next steps’ review of the Five Year Forward View regarding GP workforce,³ NHS data have recently identified an overall reduction of 96 (0.3%) in the numbers of full-time equivalent GPs in the 12 months to September 2016.⁴ Such GP workforce issues have led general practices to consider strategies for coping with increasing workload,⁵ including employing clinical pharmacists in patient-facing roles.

Pharmacists have traditionally had dispensing roles, though their degree-level training suggests that their potential has not been fully realised. Research evidence indicates that they can contribute favourably to clinical outcomes in primary care.⁶ Furthermore, increasing multimorbidity and polypharmacy across the population is contributing to the complexity of clinical care.⁷ Given this context, it seems reasonable to suggest that having additional medication-focused expertise within general practice teams may be of potential benefit.

EXTENDING PHARMACISTS’ CLINICAL SKILLS

The Royal College of General Practitioners (RCGP), in the context of describing the MRCGP Clinical Skills Assessment (CSA), defines clinical skill ‘as the ability to gather information … apply learned understanding of disease processes and person-centred care appropriately … make evidence-based decisions, and communicate effectively with patients and colleagues’.⁸ We propose that the recent initiatives in developing pharmacists to deliver patient-facing care in general practice settings require the extension of pharmacists’ clinical skills as a priority. Adding these skills to the medication experience that pharmacists already have could transform the contribution that pharmacists make to the workplace in these new roles. Knowledge that coexists with relevant clinical skills could promote pharmacists’ abilities in taking further responsibility when performing patient assessments and making clinical decisions. For example, medicine use reviews (MURs) involves patient education and discussing adherence to medication; however, further development of clinical skills as part of a pharmacist’s repertoire could be potent. With appropriate communication and skills training, clinical reviews undertaken by pharmacists could involve shared decision making with patients around starting, stopping, and changing doses of medications,⁹ thereby extending their clinical roles.¹⁰ This could enable pharmacists to contribute significantly to managing workloads in general practice and hence demonstrate the pharmacy profession as a beneficial addition to the skill-mix in general practice.

A further reason for the importance of pharmacists developing their clinical skills relates to assuring patient safety and quality outcomes of patient care. Given the potential for exposure to undifferentiated patient presentations in primary care, pharmacists need development in clinical assessment skills to identify when symptoms or signs may indicate serious disease.¹¹ This will facilitate pharmacists to appropriately request second opinions from colleagues, either because further or secondary care is needed, or if their professional competence is reached.

Physical examination of patients forms part of clinical skills. Patients are often examined during general practice consultation; however, this is not generally expected in the patient consultations that community pharmacists conduct. Thus, physical contact with patients may be unfamiliar to pharmacists and, hence, potentially daunting. Specifically, considering and addressing the inexperience of pharmacists in patient contact, along with the ethical issues around examining patients, will be required if clinical competence is to be achieved.

MINDFUL PRACTICE

Building on the confidence and skills of pharmacists is key.¹² General practice clinical work requires ‘tolerating uncertainty, exploring probability and marginalising danger’,¹³ which may represent a change in emphasis, when compared with the exact-science approach needed for the traditional medication dispensing roles of pharmacists. Mindful practice,¹⁴ a characteristic of good clinical practice, emphasises that practitioners use skills such as reflection and critical self-awareness to manage uncertainty, manage emotions, and make decisions. These abilities are desirable for patient-facing healthcare delivery, so development of such skills is necessary in pharmacists’ training for extended roles in general practice.

DEFINING AN EMERGING ROLE

Successful integration of pharmacists into primary care has been linked to pharmacists’ clarity on their role definition,¹² yet these roles are still emerging. The general practice roles that pharmacists are performing may reflect the needs of their particular GP practice population or gaps in the existing practice skill-mix, rather than a defined national role description. Research evidence suggests that health professionals have concerns when changes in skill-mix occur in general practice, and some advocate that the concept of GPs ‘delegating’ to allied health professional needs to be replaced with the notion of integrated teams working together to address any implications of uneven power dynamics.¹⁵ The design and delivery of pharmacist training for pharmacists requires an appreciation both of the challenges and potential of this professional role transition.

To date, the training structure of general practice pharmacists varies. One way has seen pharmacists transitioning into general practice teams organically, facilitated by forward-thinking individual pharmacists or practices and pre-existing working relationships.⁴ In this setting practice pharmacists report using learning from their prescribing qualification and collaborative working to deliver care to patients.¹¹

THE CLINICAL PHARMACISTS IN GENERAL PRACTICE PILOT

The recent Clinical Pharmacists in General Practice pilot, with the Centre for Postgraduate Pharmacy Education (CPPE) as the training provider, has developed a structured approach to supporting the development of this innovative role.¹⁶ In this scheme, pharmacists are employed in general practices and have access to local professional networks of pharmacists including senior pharmacists and mentors. Pharmacists on the pilot are subsidised employees in their general practices for 3 years with 60% of their year 1 salary being funded, 40% in year 2, and 20% in year 3. This approach supports the resources needed for clinical supervision. Along with this, the pharmacists on the pilot are offered up to 28 days of additional off-site training over 18 months, with acquisition of non-medical prescribing training, if not previously held, being prioritised.

CONCLUSION

There will be economic implications for practices. Pharmacists might anticipate remuneration commensurate with their qualifications, role, and contribution to patient care. As this comes at a time when healthcare services are suffering financial constraints, it is possible that such expectations may not be met, or not met in full. What can be assumed is that their employers, often GP partners, will aim to use team resources well. Employers are likely to have the aspiration for practice pharmacists to become integrated team members, contributing to the management of existing workload and initiating quality improvement activities. In doing so, practice pharmacists would promote their job satisfaction, team-working, and quality of care.¹⁷

For continuing success there will be challenges to overcome, such as defining standards for these new roles, and acceptance of patient-facing pharmacists by existing primary care team members and by patients. It is likely that the professional identity of pharmacists may change and general practice teams will need to find a new equilibrium. If these transitions can be facilitated, a bridge can be made between the patient (the ills) and the medication they receive (the pills) by using extended clinical skills. This is an exciting journey for the pharmacy profession, patients, and general practice.

Provenance

Freely submitted; externally peer reviewed.

Competing interests

The authors have declared no competing interests.