How this pharmacy team reduced inappropriate referrals

We caught up with the Pharmacist/Pharmacy Team of the Year Award shortlist ahead of this year's General Practice Awards ceremony to be held on 5 December at the Novotel London West. The Willows health pharmacy team has worked on a digital chronic kidney disease programme. They share their work here 

When the Willows Health pharmacy team set out to improve care across its 11-site primary care network (PCN) in Leicester, Leicestershire and Rutland, its core mission was to shift care from analogue to digital, from hospital to community and from treatment to prevention.

At the centre of their work is a digital chronic kidney disease programme that has reshaped how the PCN manages the condition. By integrating nephrology input and clinical dashboards into SystmOne, pharmacists have optimised prescribing of RAASi, SGLT2i, Finerenone and statins across 65,000 registered patients.

More than 500 patients have been reviewed, with 329 optimised according to NICE guidance, and 298 achieving target blood pressure. Inappropriate referrals to nephrology have dropped from 30 per month to two, representing a 90% reduction.

Related Article: Payment percentage for statutory branded medicines scheme drops to 16.5%

'I didn't know I had kidney problems until they called me in,' says one patient. 'The pharmacist explained everything clearly. They changed my tablets and followed up a few weeks later. I feel listened to and healthier than I've felt in years.'

The team has also introduced structured governance for high-risk medicines. A gabapentinoid audit showed 100% dose appropriateness, with deprescribing trials attempted in 87% of patients.

A hypnotic prescribing audit achieved compliance with 14-day maximum durations across all sites, while disease-modifying anti-rheumatic drug (DMARD) monitoring dashboards, steroid emergency cards and pregnancy prevention protocols have been embedded into routine care.

Using the Lumina governance platform, safety alerts and incident learning are shared across all 11 sites in real time.

'The pharmacy team has become the backbone of our safety ecosystem,’ a clinical director commented.

‘Whether it's the rapid response to safety alerts or their leadership in chronic disease optimisation, their interventions have tangibly improved patient care and reduced unnecessary hospital referrals.'

Working with Welby Innovate, the team has redesigned batch prescribing and recall systems using Lean methodology- an approach to process improvement aimed at reducing waste. The changes achieved an 18% improvement in clinical system speed and reduced routine full blood count and liver function test monitoring for low-risk medicines by 30%.

Related Article: Research review: a look at the latest clinical papers

In addition, administrative workload has fallen by a quarter, with staff reporting reduced burnout.

'Since the pharmacy team streamlined our batch prescribing system, we've seen major reductions in administrative burden,' says a practice nurse lead. 'They've saved us hours per week while increasing patient safety.'

A nephrology consultant who has worked closely with the team adds: 'Their clinical competence and digital innovation have transformed how we approach primary renal care.

‘The reduction in inappropriate referrals is extraordinary and directly attributable to their stewardship.'

The team's methods are now being shared across PCNs and the wider integrated care system.

Related Article: Advice for newly qualified prescribing pharmacists published by GPhC

This is the second of six shortlisted entries for Pharmacist/Pharmacy Team of the Year at the General Practice Awards. The winners will be revealed at the awards ceremony on Friday 5 December at the Novotel London West. If you’d like to be there on the night you can find out more here and book tickets here.