Rachel Carter learns about Jaysons Pharmacy's warfarin monitoring service and how it's helping patients stay healthier.

Name of pharmacy: Jaysons Pharmacy, Long Eaton and Wollaton.

Name of pharmacist: Nitin Lakhani.

Why did you start offering the service?

We've been offering this service since 2013. We are all clinical pharmacists and going down the route of clinical services was the direction of travel that the company wanted to take.

How much did it cost to set up the service?

The main cost was the training for the pharmacists, which at that time was at Aston University. The machines themselves cost £250 and we purchased two of those, and the tests strips cost around £80 for a box of 48.

What, if any, training did you or other team members have to undergo?

All of our pharmacists who provide the service have done the training. We trained seven pharmacists. The training was an online course on warfarin initiation and maintenance with the British Medical Journal, and also going to Aston University for one day to do a practical and supplementary training.

In a nutshell, what does the service involve?

Where patients are identified with atrial fibrillation, they are at a slightly higher risk of having a stroke. To mitigate that risk, doctors used to start patients on warfarin. But warfarin has a very narrow therapeutic index, so it has a very narrow window to be beneficial. Over a certain dosage can thin the blood too much and cause an internal bleed, and below that small window, the blood is not thin enough and therefore the risk of stroke increases back to what it would be if they didn’t take the warfarin.

So, the surgery identifies the patients with atrial fibrillation who are on warfarin and gives them a choice of two or three providers they can go to in the area for monitoring. Our pharmacies are among those providers. We check their blood warfarin levels and ensure it is within that narrow window.

The patient can come into the pharmacy, we take the blood sample, it’s just one drop. We work out the dosing from that and document it. One record goes to the doctor, one record goes in the patient’s yellow book, and one record goes into our files. We also provide a home service as well for housebound patients. Because we have trained enough pharmacists, no matter who is away, we are able to provide this as a six-day service.

Are there any opportunities to sell over the counter or prescription products during the consultation or after it?


How have patients responded to the service?

We do an audit of patient feedback and it’s been excellent. Previously patients would have to go to the hospital, which meant driving down there, waiting, car parking, all of that. Or, if the surgery did the test, then the phlebotomist would have to take a bottle of blood, send it off and the results would come back the next day. Whereas with us, it’s straightforward.

We did some training with the patients to explain to them how the service works and to try and understand, if their levels had gone up or down, what might have caused that. As pharmacists we also look out for any interactions with their medications as well. All of this has meant the total time in range [within the therapeutic index window] was, proportionally, for our practice much, much higher. I remember in the old days the total time in range on average patients should be at was 60% - now it’s 65%. But for our patients it’s about 85%, on average, so the service is much safer for them as well.

Roughly how often each month do you carry out the service?

We may have around 10 to 12 appointments per day, but that’s on average. Some days it’s higher than that, and other days it’s lower. It all depends on how well the patients are and how their appointments work - a lot of patients like to stay with a fixed day every week and will always come on that day. But if their warfarin level [international normalised ratio] is maintained, then the interval between appointments increases and we see them less and less frequently. The maximum interval period is up to 10 or 12 weeks.

How much do you charge for the service?

The service is free to the patient. We are paid a fee per patient per month.

Roughly how much a month do you make from offering the service?

Figures not available.

Would you recommend offering this service to other contractors?

Definitely. I think first and foremost, it’s about understanding the new NHS - there’s a supply side and there’s a service side. On the service side there’s different tiers, ranging from those that counter staff can provide, through to technicians, pharmacists, and then the specialist pharmacist - so four tiers.

If you are going down the clinical route, then the more clinical services you provide, the more uptake there will be - and there will come a tipping point after a certain amount of time where it starts to become viable. The setting up, systems, training, operating procedures, premises and IT structures initially have a lot of cost and you’ve got to provide enough of the services before you start to see a penny back from them. But only after doing that, will it start to supplement the low dispensing fee that is currently being paid.