For our Pharmacist in Practice series, The Pharmacist spoke to Hitesh Tara, senior clinical pharmacist at East Warwickshire PCN, about local priorities in a rural population, and the importance of effective communication between colleagues in general practice, secondary care, and community pharmacy. 

Tell us a bit about your role and how you got there

Our team has developed since I became our first clinical pharmacist back in 2019. We have a team of five of us pharmacists at the moment, and a pharmacy technician who has joined us too.

Before then, I was in community pharmacy for a good while, and I think I just got to the stage where I wanted to do something different. I’d kind of reached my peak and at the time, I felt as though it wasn’t possible to use you couldn’t use your clinical ability as much in community pharmacy – but I think things really are changing now. Then, I would have people come to me in the community pharmacy with their blood results and I wouldn’t be able to comment on them because I couldn’t see their trend from before; I’d have this one piece of information and nothing else.

Working for a community pharmacy that was within a medical centre was the first time we came face-to-face with the GPs. It was great just to be able to pop in and have a chat with the GP, and I found that if you’re integrated – and a friendly face – clinicians will ask you for advice.

I think I was seeking some form of change. I went to Leicester and did a postgrad there in clinical pharmacy while still working in community. That opened a few avenues, and one of them was moving into general practice. At the time, PCNs were developing, so I did a lot of research about the roles, applied for quite a few of those, and got this position. I think I actively tried to make myself a bit more attractive for the roles by doing clinical pharmacy, and that really helped.

What additional training have you done?

I’ve done my PCPEP (primary care pharmacy education pathway), which every clinical pharmacist needs to do when they join general practice. That's an 18-month training programme, with a mixture of study days, assessments, physical assessments, and physical exams that are within our competence, and consultation assessments. You have a clinical supervisor who's normally a GP. After that pathway, I did my independent prescribing course.

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

We have clinical pharmacist sessions in all our surgeries – both face-to-face and telephone appointments. Usually, there’s a morning clinic from around 9am until lunchtime, and within that clinic there will be a mixture of things. We do plenty of structured medication reviews for high-risk patients that have been identified as people that require attention to their medication. That’s part of the network DES – one of the things required of clinical pharmacists to hit our targets.

We also see patients with chronic diseases. We might have patients coming in just for the odd issue, like problems with their blood pressure, or they may have had a heart attack in the past and they need their annual review or their annual Heart Failure Medicines Review. Sometimes we do some pill checks or HRT reviews – so it’s loads of different things.

Then we have a gap before afternoon clinics. Within that time, we’ll have our lunch, but we’ll also deal with any queries from the clinical staff and admin staff as well. They send tasks through on our computer system and we clear them – so we might be asked things like: ‘We feel this patient might need a medication review’, ‘This patient's having trouble swallowing this medication, can it be crushed’ or ‘Are there any contraindications for this particular medicine, for this particular indication’?

We also deal with communications from secondary care – so for example, I might have written to a consultant for some advice about a specialist area: I'll need to see to their replies, and might need to look at some lab reports if I've requested those as well.

Then we would have an afternoon session where we would do some more clinics.

The clinics have definitely not happened overnight. When I first started, I was on my own in the area. During the pandemic, there was a large element of working from home and I took this opportunity to set up the first clinical pharmacist clinic. I found this difficult while working from home and so returned to the surgery earlier than planned to develop this further.

How do you work in a team with your practice colleagues? 

We work alongside the GPs, nurses, admin and clinical staff. We're part of the team, and we have access to the medical system. We can see the consultations that have taken place, the observations and results, and any letters back and forth from external organisations, hospitals etc, which we need in our day-to-day practice. We have all that information on hand.

I had a patient with high hypertension a few weeks back: a couple who were measuring their blood pressures at home. BP was elevated, but they'd seen the GP a week before and the GP had measured a normal blood pressure. Their BP machine was about eight years old, and you can't really base a prescribing decision on inaccurate information, so I got them to come in that day. We did a pulse check as well, and we found out that actually the blood pressure was normal. It was just a machine that was out of calibration.

You can’t do that in a telephone appointment. And you can’t do that if you just have one piece of information and nothing else. It's really important to have that bigger picture.

How do patients feel about seeing a pharmacist and not a GP?

This was always at the back of my mind when I started. When you speak to someone, especially on the phone, they probably only remember the first three things; that's it. So, I'd always say: 'My name's Hitesh, I'm one of the clinical pharmacists and I work in the surgery’. So ‘This is my name. This is what I do. And I don't work at the pharmacy’.

Patients now remember me. We had one patient who was moving between practices, and he booked a face-to-face appointment with me at his new practice, because he said he just wanted to see me and what I looked like! So, it’s really nice.

I think patients trust their GPs, and if they can see that the GPs are trusting us pharmacists, that makes it very easy.

How do you find working across several different practices? 

Every surgery does things differently. For pharmacists who are training, it’s really nice to have exposure to different GPs because they'll have different ways of working. It moulds that clinical pharmacist into a more adaptable person.

How do you work with community pharmacists? 

It’s really important that the community pharmacists are aware of what we're doing and they can let their teams know, so that all parties are involved. Whenever I speak to them, I always record in the notes that I've spoken with X, Y and Z and this is the plan going forward. It's really important that any changes – to medication, for instance – are done very smoothly and safely.

I'm known in our community pharmacy. They know who's on the phone, and I think they like it because I know it from their side, and they have someone regular from the surgery to speak to. I've also noticed it the other way around too: there was a query this week that came through from a patient to reception; reception spoke to the pharmacy, and directed them straight to me.

Communication between us all is really important. I think the patient then feels very well taken care of, because they can see that everyone's speaking to each other – perhaps something that I don't think happens too much across primary and secondary care.

With everyone becoming independent prescribers in a few years’ time, do you think changes need to be made?

I think this is the big question mark. I do the occasional locum shift for community pharmacy. We sometimes get CPCS referrals, and of course there are an increasing number of pharmacists becoming prescribers in the community.

The concern I have is around access to patient records. If you don't have that bigger picture, then I don't know how prescribing can happen in community. I don't think it's safe, because there are all those little things you need to know. What's happening in that patient's life? Have they had a marital break-up? What was their trend in bloods before? If they went into hospital before for a fracture, how long ago was that? All of these bits of information: - blood results; recent interventions made by people in the practice – you don't always have that full picture in community pharmacy. So, I'm still waiting to be convinced on that. In some situations though, it would definitely reduce the load on NHS 111 and ambulances for things that can be dealt with in the community.

I’d like to see community pharmacy become more clinical. I feel as though the scope is there, but community pharmacists need to be given the ammunition as well. They can't just be told, ‘Right, here, prescribe and reduce the load’, because that's just not safe and it's going to cause havoc. Slowly but surely, I'm hoping that they get that ammunition, and they get more access to patient records. It all comes down to seeing the bigger picture. As long as community pharmacists have been trained and have the information that they need, I don't see more clinical work being a problem.

What is the biggest patient need in your area and how does that influence your work?

We have quite a rural population with a lot of elderly patients, and young families as well. We’ve got a nice mix – it’s very different from an inner-city practice. In our structured medication reviews, we look at certain indicators: patients in care homes, people who are frail, elderly and at risk of medication error and high use of addictive medication for pain. We also look at chronic diseases.

One need that I have picked up on, which is very common within this geography, is overmedication. We’ll have a lot of patients on a mixture of pain medications – sometimes they are all indicated, but sometimes they’re not.

We had a case recently that I worked on closely with the community pharmacists. They do the dosette box, and we do the prescribing. This patient was very drowsy throughout the day, sleeping for about 15 to 18 hours a day, and highly medicated. In agreement with them, we found that by reducing their amitriptyline there was no difference at all in pain, but the patient was a lot more alert. We’re now working on their gabapentin, etc. It's a slow process; it's trial and error, but it's worth doing.

It can be a sensitive subject to bring up with the patient, because these are medicines they've been using for a long time. Sometimes, they're very protective of them, and it's really important to understand that and make sure it's always a shared decision. If you approach it like that, they can see that you genuinely care for them and you want their health to be better, and they normally agree to it.

Do you have any areas of special interest or any particular projects that you’re working on? 

I have a special interest in anticoagulation. During Covid, we were given a task of switching a lot of patients from warfarin to DOACs, and initiating DOACs, to reduce face-to-face contact during the pandemic – if it was suitable and the patient was in agreement.

That was a new area for me. We were given a lot of training by our GPs and the leads within our federation, so that’s how I gained competence in that area. Through my prescribing, I also sat in with my local hospital and went to their anticoagulation clinic. I saw more about acute DVT presentations and how they triage things over there. Generally, I've just developed an interest and have become competent within that area.

If someone came in with an acute DVT type symptom, that would be seen by the GP, but I do long-term management. For example, if someone had had a DVT and they hadn't been reviewed, I would review them and communicate with their consultant haematologist, who would decide if they should have a continuation or a dose reduction. The clinical pharmacist is perfect for that back-and-forth communicating.

What do you think will be the biggest opportunities/challenges in the sector as a whole over the next five years? What changes would you like to see? 

I think one challenge will be how we break this barrier between primary and secondary care and make sure communication is all a bit smoother. Sometimes there's a lot of back and forth, with letters and the like, and communication could be better.

One thing that I would like to see would be to have an ‘interface pharmacist’ – someone who works half the time in general practice and half the time in the local hospital – so that there's integration and hopefully care would be more seamless.

My understanding is that the ICBs are going to be working more as an interface between secondary and primary care, but it's all early days at the moment.

And something you like to do in your time off?

In my spare time, when I get it, I quite enjoy going to the gym. I like weightlifting: it’s a stress reliever.