For our Pharmacist in Practice series, The Pharmacist spoke to Kerry Clay, lead clinical pharmacist at DeMontfort Surgery, Leicester, about responsibilities in the practice, managing shared care medication, and working with community pharmacy.
How long have you been working in general practice and what were you doing before? What attracted you to working in general practice?
I’ve been here two years – I started in February 2021 - and it’s flown by because every day is so busy. I was working with the Clinical Commissioning Group for 10 years previously, and before that I was in community pharmacy.
I was contacted by the practice asking if I was interested in working with them and that they would really value my help. I’d been lucky enough to work with the practice before while I was working with the CCG, and therefore knew it was a lovely practice to work for with good management. They had a team of two pharmacists who were both part-time and they needed an experienced pharmacist to provide guidance and manage the team. We’re advertising for two more pharmacists in the coming months as there is always plenty of work to do.
As a practice pharmacist, you’re usually employed by the PCN, so the practice receives ARRS funding to employ you. As part of the role, you undertake the CPPE 18-month pharmacist in GP practice pathway. Once you’ve completed that, you go on to do a six-month Independent Prescribing qualification. At that point, you become even more beneficial to the practice as you can take on additional roles such as managing patients with long-term conditions and, because you can prescribe independently, you don’t need to involve the GP and can work independently, rather than just doing the structured medication reviews that you were taken on for originally.
Are you currently undertaking any training? How is it going?
I’m at a point now where I’ve completed the 18-month pathway and I’ve started doing my Independent Prescribing course at Huddersfield University which will be completed in July. That wasn’t an opportunity that I’d had when I worked for the CCG, now the Integrated Care Board. I think many community pharmacists are funding themselves to do it, but if you work as a PCN pharmacist in a GP practice it’s funded by Health Education England, which is a brilliant opportunity. I feel quite late on in life to be doing university work, and I thought my uni days were over, but it’s good to have a challenge. The thought of having the exams is filling me with fear every time I think about it, but it will be worth it.
Do you have any areas of special interest or any particular projects that you’re working on?
My interest is in respiratory conditions, particularly asthma and COPD. I enjoyed working in this area when I was working at the CCG and was involved in writing guidelines. Now my role involves implementing those guidelines in practice and making sure that, for patients with long-term conditions like asthma and COPD, their medication is optimised, they’re not having any side effects from it and the medication is treating them effectively. Managing patients and improving their symptoms from these conditions is really rewarding.
GPs also have an increased workload these days: they’re seeing so many patients, there’s never enough time for them in the day, and so as pharmacists you are taking some of the workload off them. It is quite a large workload – there are things like medication reconciliation, where you’re speaking to patients recently discharged from hospital on new medicines to ensure they know how to take it and making sure they’re not having any side effects. That’s rewarding and that’s only part of the role that we’ve taken from them.
There’s lots of new shared care medication coming to primary care and the pharmacists can help manage the patients taking them, as well as medicines safety alerts. The GPs were aware they had to do this on top of seeing patients in surgery but struggled to find the time to do it. So, when a GP says, ‘I’m so pleased you’re managing all of this, it’s such a weight off my shoulders,’ that’s a good sense of job satisfaction as well - you’re helping the GPs so that they then have time to see the patients and concentrate on managing acute conditions. It’s the same with long-term conditions. Because we’re managing those, it gives them the time to see people who are acutely unwell.
What does your job look like day-to-day?
As PCN pharmacists, we are tasked with doing structured medication reviews, and this year as part of the government focus, we are being asked to focus on patients who are taking drugs of dependency, particularly patients who have been taking benzodiazepines, hypnotics or gabapentinoids long term. We had about 200 patients that needed a structured medication review.
We’re also doing structured medication reviews for patients who are in care homes. Once every couple of weeks, we go out to visit them and make sure that they’re not having any unnecessary medication, they’re able to swallow their medication, and that it’s not causing any side effects. A large part of our workload is doing structured medication reviews on patients with polypharmacy and sometimes if you have patients taking 20-30 medicines a day, they can take a long time.
The other part of our day can vary widely but would usually involve responding to requests for acute and repeat prescriptions or queries about side effects. We also answer queries from pharmacies if they can’t obtain medication.
We also implement medication alerts. Recently we had a drug safety update about testosterone gel alerting prescribers that the gel can be transferred to children accidentally from the patient. That means that we have to contact all our patients who are using testosterone gel. Dealing with medication alerts such as these is high priority and an important part of our job.
We’re also looking at managing prescriptions of high-risk drugs to make sure that the patient’s monitoring is in place. For example, DMARDs for rheumatoid arthritis – they require regular two to three-monthly blood tests. By doing that, you’re ensuring that it’s safe to issue that prescription and for the patient to continue that medication, which is really important.
Part of my role has been finding and implementing safe pathways for these high-risk drugs to be issued. Standard operating processes are a large part of what pharmacists can offer practices as attention to detail is something pharmacists are really good at.
How do you work in a team with your practice colleagues?
The pharmacist team works alongside the practice nurses, GPs, mental health nurse, social prescriber, administrators, phlebotomist, and receptionists. You’re working as a team together and we have regular clinical meetings, so we rarely feel isolated at work.
How do you work with community pharmacists?
We try to work closely with our two local community pharmacies. If there’s a new service that they’re doing, I invite the pharmacist to come in and speak to the clinicians about it. We implemented the Community Pharmacy Consultation Service and worked out a process where we can refer patients to them who have minor illnesses, such as urinary tract infections. And if there’s any reason they can’t treat the patient as their condition is more complex, for instance they’ve got kidney pain and it’s not just a simple UTI, we have a referral process where they can refer the patient straight back and we’ll get them seen by the on-call doctor that day. It’s finding how to implement and create an efficient service for the patient with minimal disruption, so that we’re confident that the patient is going to be treated when we send them to the community pharmacy.
They’re also doing a hypertension-finding service and they can do 24-hour blood pressure monitoring, so we will refer patients over to them for that.
It’s all about communication – by inviting the pharmacist into the surgery they can see how you work on this side and envisage any problems that we might have with the service before we launch it. I also think having a pharmacist in the practice improves the two-way communications between the surgery and community pharmacist colleagues immensely. Community pharmacists feel more comfortable contacting us and speaking to a peer, whereas previously contacting GP practices could be quite daunting. My local community pharmacy colleagues are so helpful and keep us well informed about stock issues.
What is the biggest patient need in your area and how does that influence your work?
We’re right next to De Montfort University in Leicester, so we have a high proportion of student patients, and also many patients who live in inner-city Leicester. We see patients for sexual health services, and we’re seeing increasing numbers of patients with mental health problems and anxiety.
Other than that, we’re an inner-city Leicester practice as well and we there’s a lot of poverty in the area and deprivation. We don’t have so many of the long-term conditions that they might do in the suburbs, it’s quite a different patient population.
We have many patients from abroad, both international students and people who’ve moved to the UK permanently that need interpreters, so that’s quite time-consuming, but also really interesting. Many patients are taking medications only available abroad, so we have to find out what the UK equivalent is. We have challenges such as many students from abroad have experiences of different healthcare systems which are often private and they are used to being able to get whatever they want on prescription, therefore some of the role is managing students’ expectations of what is available on the NHS.
A big challenge in the NHS at the minute is waiting lists to see some secondary care NHS services. Some patients are forced to seek help from private services due to long NHS waiting lists, particularly for mental health services such as ADHD clinics or referrals for transgender clinics. The NHS waiting list for this is currently about three years.
What do you think will be the biggest opportunities/challenges in the sector as a whole, over the next five years?
Once you’re got your independent prescribing qualification, it opens a lot of doors to being able to manage patients with long-term conditions, depending on what your interest is. It doesn’t need to stop at independent prescribing. I know that some pharmacists then go on to do advanced clinical practitioner courses and then you’ll be able to see acutely unwell patients and deal with minor illnesses. There’s lots of scope for progression.
For instance, there are no GPs here with an interest in respiratory conditions, so they’re looking forward to me qualifying in my independent prescribing with an interest in respiratory conditions. It’s finding that gap requirement in the practice and developing your skills in that area.
There may also be opportunities for pharmacists to become practice partners. I think I will be managing more patients in the future. A lot of it is about the GPs becoming confident in the pharmacists that they have. Also, when you’re new to independent prescribing, you’re going to be very cautious, like when you’ve just passed your driving test, and then the more patients you see, the more confidence you have and the better you’ll become. Then the GPs will have confidence in you and will utilise your skills in that area a lot more, because it’s still very new to them as well.
What changes would you like to see?
I’m concerned about how long the government will continue to fund the ARRS roles, and whether the practices will keep employing pharmacists if the funding were to stop. When pharmacists were originally funded in practices in 2019, the ARRS scheme aimed to recruit pharmacists over a five-year framework. It’s not clear if, after five years, the GPs would have to pay the pharmacist’s salary. As soon as that funding is pulled, would the practice continue to pay you? It’s a bit of a concern and I’d like the government to provide more communication to anyone employed in ARRS roles about future plans.
What do you like to do in your time off?
I’m a big Newcastle United supporter so I enjoy watching the football. I also enjoy spending time with my two children, particularly taking them swimming. I’m a keen reader and enjoy jogging, and hopefully I’ll be successful in the Great North Run ballot this year.