For our Pharmacist in Practice series, The Pharmacist spoke to David Jenkins, pharmacist at Meneage Street Surgery, Helston Medical Centre and South Kerrier PCN, Cornwall, about his work in areas such as medicines safety, processes and audit.
How long have you been working in general practice?
I’ve had what they call a portfolio career since 2005: I worked for the PCTs as they were then, and then they became CCGs, on a sessional basis, going into general practice in the early days when pharmacists in general practice weren’t routine. Because Cornwall’s got such a high proportion of dispensing practices, they traditionally saw pharmacists as opposition. The challenge in those days was sometimes just getting in the door to show how you could contribute.
I did that while working in community pharmacy, and I always felt that by understanding how it all fits together, you can do both sides of the job better. Then I was employed by a couple of surgeries, and since 2018 I’ve been in my current role, directly employed by a couple of practices in Helston and seconded a bit to the PCN.
I’m not a clinical pharmacist; I don’t have any clinical qualifications in the new PCN roles, but I’ve got a slightly unusual protected role.
I’m given the freedom and protected time to think in-depth about processes that no-one else in the building has got time for. My driving obsession is, how can we make change stick? How can we make a difference in a sustainable way?
What attracted you to working in general practice?
I went from managing a pharmacy to locuming, and they were setting up some pharmacists in general practice. Initially, it was two days a week, and I just enjoyed it and took to it. The practices I worked with were very receptive. We still hear and read a lot about pharmacy struggling to justify itself in general practice; I’ve never really had that. I’ve always enjoyed good working relationships and a lot of respect. It disappoints me when I read that people are struggling.
How do you work in a team with your practice colleagues?
We (the pharmacy team) are very lucky in South Kerrier PCN to be truly integrated into the primary care multidisciplinary set-up – we make recommendations in various areas, clinicians listen, we agree a policy and stick to it.
A lot of my work is based around processes. A good example would be something like medicine safety, so you have a group of high-risk drugs, DMARDs are a good example of that, where you need regular monitoring and to make sure the drugs aren’t doing more harm than good. But if you’re a GP and you’re filing test results at eight o’clock at night and you see a blood test out of range, unless you are thinking that patient is on one of these high-risk drugs and put those two facts together, you’re going to miss it. And this is when you get significant events. The good thing about computers is they never miss anything and they never get tired, so you can build safety searches in modern systems that will put those two facts together.
We’ve built lots of safety searches that run automatically, some of them are weekly if they need urgent action, but most of them are on a four-weekly cycle. And we’ve got very detailed standard operating procedures for the pharmacy tech to work through. If a result is out of range, they know what to do to follow the required pathway. The first thing is, was it noted when it was filed? If it’s clear that that’s been noted, that’s fine. If it hasn’t been noted, then a task is sent to the GP. Some things the pharmacy tech can do themselves. If you’ve got a drug combination that needs another drug to protect the stomach, for example, then they will do that themselves because they’ve got a protocol with a standard letter that’s sent and doesn’t need to go past a clinician. That’s where my strength and my role is, getting these systems in place, so that patients are safer.
Whenever the GPs receive a notification from the pharmacy team, they tend to respond very quickly, because they know it’s been screened and if it’s coming to them, they know it’s something that needs their attention, so that’s very well received. I’ve had a lot of very positive feedback about that aspect of it.
We do a lot of audits, and I also make sure prescription clerks that issue prescriptions on request have got a standard operating procedure.
Four of us have got some funding to set up what we’re calling a ‘pharmacy forum’ to have regular meetings and basically help and support pharmacists new and established in general practice and share best practice. The first meeting is hopefully coming up in early March, and that’s quite exciting. It is a model that nurses in Cornwall have used for a long time and we’re looking to replicate and establish it for pharmacists and pharmacy technicians as well.
What does your job look like day-to-day?
We deal with a fair amount and variety of tasks and queries that come through, on medicine management usually. It’s difficult to say because I’ve usually got several quite big projects on the go, whether I’m supervising somebody else or doing them myself.
There’s a lot going on at any one time and there’s a lot of training going on, so I’ll be helping train pharmacy techs and the prescription clerks, there’ll be audits ongoing, audits in the future and helping to write the standard operating procedures for these batch reports.
Do you have any areas of special interest or any particular projects that you’re working on?
Over the last few years, we have done a lot of work on atrial fibrillation (AF). We recently completed a project on AF Protect, helped by an outstanding Bath University placement student. We have ended up with a tool which will rapidly identify, for example, patients who previously declined anticoagulation whose CHA2DS2-VASc score has increased since making that decision, and patients who were prescribed anticoagulants but who have apparently stopped taking them. In both these cases, a review with a clinical pharmacist would occur.
The tool is an example of sustainable improvement to practice because it takes seconds to run, always with up-to-date information, and we will run it every 6–12 months. It’s about how we can make sustainable change and make change stick, otherwise you run it once, you think you’ve done it, it’s very easy to fool yourself into thinking you’ve done a good job, when in fact what you’ve done is firefighting.
The next big project I plan to explore is around bone health. We have an ageing local population, and many fractures are associated with very poor outcomes.
What is the biggest patient need in your area and how does that influence your work?
It’s an ageing population that is geographically isolated, so the PCN has invested in the pharmacy team and social prescribers, because it’s often isolation that drives health inequalities. They’re the biggest challenges.
I’ve come in to look at the drugs that are most risky in an ageing population. They’re the same drugs that any pharmacist ought to be highlighting – the DMARDs, the anticoagulants, the antiplatelets, the opiates, and so on.
The thing that really drove it was Covid because we were wanting people not to come in unless necessary. So you have to then start making very sure that your high-risk monitoring response is appropriate, so those that do need to be seen, will be.
How do you work with community pharmacists?
I still work across both sectors and I’ve always felt that by working in both camps, you understand the difficulties for both sides. I’ve spent a lot of time helping those relationships between community pharmacy and general practice and the CCGs.
A very good example of this is setting up a repeat dispensing system. I love repeat dispensing but it tends to be set up very badly. By understanding the difficulties or issues on both the pharmacy side and the clinical side and general practice, you can set up a much more robust and efficient system.
In one practice we’re looking at about 800 patients on repeat dispensing. Pharmacists and dispensers in the area have told me it’s the most efficient, lowest hassle repeat dispensing system they’ve ever been involved in. I think that’s entirely due to understanding how it works on both sides.
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?
The first thing is that the gender pay gap is outrageous. We are a knowledge-based profession where the majority of the talent pool is female and gender is no more relevant to doing the job well than eye colour, so why is there a pay gap? The fact there’s a gender pay gap at all is an insult to common decency. The three most inspirational pharmacists I have known are women. Stop this nonsense. Pay people properly.
The second one is Schools of Pharmacy. Teaching clinical skills is great, but Schools of Pharmacy and the wider profession shouldn't lose sight of the fact that our expertise is medicines. We bring a unique skill set to the multidisciplinary group. GPs can read the BNF as easily as we can, so what does being a medicines expert actually look like in general practice? You need to know where to find evidence, how to interpret that evidence and present it clearly and concisely to both other healthcare professionals and patients. I would like to see more emphasis on critical thinking, statistical analysis and evidence-based medicine in both degree courses and continuing education.
As an example, I had a GP asking me about an elderly lady on two antiplatelets, aspirin and ticagrelor. Aspirin is once a day; ticagrelor is twice a day. She’s quite elderly and the lady’s daughter was concerned that she might miss the second dose of ticagrelor and asking if it would be possible to switch to a different drug that’s only once a day? And there is such a drug, clopidogrel. You have to understand the difference between relative and absolute risk, you have to assess the likely effect of missing the odd dose compared to a lot of doses. And then underlying all of that is the question of whether the daughter’s concern is reasonable or not, what is the actual patient likely to do? It might be that all that is needed is a medicines reminder chart from the pharmacy. That is being a medicines expert in practice rather than in theory. You need to understand all of those aspects to give a sensible answer and make the right call.
Number three is that community pharmacies are struggling at the minute to retain people. There’s tension and concern about pharmacists and pharmacy technicians essentially moving from community pharmacy into general practice. The simple answer is that people who feel valued and are happy in their work don’t move. What is community pharmacy doing that makes the environment less appealing? That’s a big challenge. Part of it is that pharmacists are still spending an awful lot of time accuracy checking prescriptions.
And what do you like to do in your time off?
I’m a keen cyclist – Cornwall’s got some of the best cycling territory in the country!