Pharmacist in practice: In a clinical role, you need to be aware of your competence

As part of our pharmacist in practice series, the Pharmacist speaks to Tapiwa Vernon Mukori, an advanced pharmacist practitioner working in general practice.

Where do you work and what does your role involve?

I’ve been working in Immingham, Lincolnshire, which is a rural part of England, for nearly four years now. I was part of the first cohort for clinical pharmacists working in general practice in 2016 and I've been working in general practice since.

I also work two days a week at the University of Lincoln as a senior lecturer in advanced clinical practice.

What made you want to work in general practice in the first place?

I was a pharmacy manager for Sainsbury's before I came to general practice. I think what attracted me to general practice was the prospect of working in a more clinical role, which was something I felt like I wasn't getting much of in community at the time.

What does your job look like day-to-day?

The practice I work for uses a system called askmyGP, which is an online platform where patients can request appointments and put in queries.

All clinicians are connected to that – GPs, nurses, pharmacists – and then work is navigated around the appropriate clinicians by the administration staff.

Before Covid, I was supporting the practice with asthma reviews and reviewing asthma patients, because I have done a diploma in asthma, as well as in diabetes. However, since Covid, due to the increased demand in general practice, the practice has adopted a more generalised approach to things, so I work with pretty much whatever is in demand on the day.

Since Covid the demand for GP appointments has significantly increased. Then there’s also been an impact of GPs leaving the practice – we’ve had two GPs that have just retired at the end of last year. All of those factors have contributed to the increased in GP workload and my role has evolved to support that.

Most of the enquiries that I'm dealing with are same-day appointment requests, ranging from long term disease management, blood pressure that is out of control, diabetes, asthma, processing patients’ end of life medication.

If there was a patient that I felt probably was more suited to be seen by a GP, they are sent back to reception to make a booking with the GP, vice versa if GP felt that the pharmacist is more suited to deal with the patient. Usually that’s around medication issues, problems, reviews, questions, that kind of thing.

I also work with other members of the clinical support team, like healthcare assistants within the practice if you needed a urine dip, working with district nurses, Macmillan nurses around palliative care, speech and language therapists if there were swallowing problems.

I also work with district nurses, reviewing patients they've seen in community, which can be wound infections, urinary tract infections, respiratory infections – so it’s very broad.

Do you enjoy that multi-disciplinary approach?

Yes, definitely. I qualified as a pharmacist in 2011. My training then was around providing pharmacy services in a hospital setting or a community setting, I did my pre-reg in hospital and in community.

But since 2016, and even now, the role has evolved to become more clinical. And with that, there’s more awareness needed of your boundaries of competence of what you're able to do.

And that awareness then necessitates for you to work in a multidisciplinary team where you would then signpost patients to an appropriate practitioner if something was outside your level of competence.

What helps you decide what’s in your sphere of competence?

I think it's something that comes with practice. And the advanced clinical practice training that I had has increased my awareness of my own personal capabilities and competencies, helping me to know what I'm comfortable to do with and what I'm not comfortable to deal with.

What training have you done as part of your role in general practice?

I started with the CPPE 18-month pathway for pharmacists training in general practice, with the University of Manchester, then I did the senior pharmacist training with them, another 18 months. While I was doing that in 2017, I also did the independent prescribing course.

Then after that, I started the Master’s in advanced clinical practice, which I finished last year – it took longer than expected because of Covid.

How do you work with community pharmacy in your role?

A good example would be the most recent episode of group A Streptococcus infections that we had within England. Patients were initially reviewed in community pharmacy, who would then refer patients that they felt were of concern.

Then day-to-day there have been issues since Brexit in terms of medicine supply, so we work closely: community pharmacists recommend alternatives, and if something is out of stock they contact me directly if they need a prescription amending. Now, those queries don't normally need to be dealt with by the doctor because we've got non-medical prescribers, pharmacists working in general practice who can easily make those kinds of amendments, and who will generally be much easier to get hold of than a doctor.

What’s the patient need like in your area? Are there any particular issues that you’re seeing that influence your day-to-day work?

The sheer demand of general practice services. At the moment we cannot even fully satisfy the requests for appointments that are made on the day, the system is overloaded. Patients need attention by a clinician – doesn’t matter whether it's a doctor, whether it's a pharmacist, whether it's a nurse, patients need to speak to somebody.

There are efforts out there, to increase capacity to meet that need, but again, there are only so many trained clinicians to be able to deal with that. It's at an impasse at the moment, right across the NHS.

What do you think are the biggest opportunities and challenges in the sector as a whole?

The challenges are obviously capacity and staff morale.

Part of the reason why I felt that it was probably wise to split my role between general practice and the university was that working 9 to 5 in the NHS Monday to Friday is very tiring. Most clinicians are reducing their hours just to avoid burn out. And they’re giving sweat and blood in the job; there’s low staff morale. And we’re in that era of increased living costs, so there are issues around reimbursement, are people getting paid enough?

But the opportunity is that there is a pool of talent within pharmacists where with some extra training, they can become clinicians that can support general practice and hospitals in various forms.

Nurses have managed to advance themselves and put themselves out there as a profession in terms of how they can support - you have nurse practitioners in hospitals supporting hospital clinics, you've got nurse practitioners working in general practice running clinics.

I believe that pharmacy is just as equally capable. The traditional training is not really geared towards them working in a clinical role, but that is changing.

Do you think anything needs to change to help the profession take on that more clinical role?

One of the things that I see, at least with practitioners, is that because the advanced clinical practitioner title is not protected, people ask me – what's the benefit of me becoming a clinical practitioner when I can work in community and earn just as much?

Unless somebody has got a keen interest in working in a clinical role generally, then that could be a deterrent because they are taking on more responsibility, working as a practitioner not really getting reimbursed appropriately.

I don’t know what it would mean for it to become a protected title. Perhaps we need something similar to doctors of royal colleges, to formalise practitioners, and protect them, and hopefully that would come with better reimbursement arrangements and all that.

And what do you like to do in your time off?

I like going for bike rides with my children, and I also go to church regularly.

Read more about clinical pharmacists working in general practice in England.