Pharmacist in practice: we're a ‘one stop shop’ for the patients

Libby Kennedy is a pharmacist based at Newcastleton Medical Practice in the Scottish Borders.

How long have you been working in general practice and what were you doing before? What attracted you to working in general practice?

I graduated from Heriot-Watt University and, following my pre-reg year in Kent, I started working at Ninewells Hospital in Dundee. I worked there for 11 years and studied for the MSc in clinical pharmacy at the University of Strathclyde during that time. I was one of the first clinical pharmacists employed there. I then had a career break to have a family after marrying a GP and we came to work in Newcastleton, a small, remote and rural village in the Scottish Borders. It is a dispensing doctors’ surgery and we cover an area with a 15-mile radius.

After a couple of years, I was asked to come and work in the surgery.  At first, I just helped with running the dispensary and checking prescriptions. My role has expanded over the years, and I subsequently embarked on the training to be an Independent Prescriber. I’ve been working in general practice for over 20 years now and I am also part of the Borders pharmacotherapy team.

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

We employed a pharmacy technician a couple of years ago who has excellent community pharmacy experience. She now heads up the dispensary and checks all the prescriptions so the GPs and I can concentrate on the clinical reviews of prescriptions. It’s a very tight ship and we aim to deliver the best care to the patients on our list.

I now run the asthma and COPD clinics, carry out medication reviews, review the medication reorder slips and keep them up to date, carry out medication reconciliations, review discharge letters from hospitals and clinics, undertake polypharmacy reviews, discuss medication-related issues face to face or over the phone, do specific reviews of medicines (for example, those affecting QT interval), visit patients at home and many other tasks that are directed my way on a day-to-day basis. I also check that patients are not over-ordering things like salbutamol inhalers, or under ordering. I feel we can offer a very efficient ‘one stop shop’ for the patients.

A recent example of this was a patient who was on Levothyroxine 75 micrograms and I reviewed her recent thyroid blood tests. I decided she needed an increase in dose to 100 micrograms. I found that she hadn’t collected her current prescription for 75 micrograms, so I prescribed and dispensed the 100 microgram dose and added a letter to her medicine bag informing her of the change and when she had to return for repeat blood tests. It is all very joined-up. If the patient was receiving their medicine from a  community pharmacy the dose change would not have been so instant and seamless.

The GP may ask me to review medications for blood pressure, hypertension, diabetes etc. and I am able to change the prescription and put it through the dispensary.

I am particularly enthusiastic about asthma and COPD and making sure patients can use their inhalers properly.  In the ‘green agenda’ I feel the most important thing is to have the right inhaler for the individual and make sure that asthmatics are not over reliant on their salbutamol.

Recently we have had to face a lot of medication shortages. One example was when we couldn’t get valsartan, but I was able to review and prescribe a candesartan dose equivalent and inform the patient accordingly. It’s so joined-up and there is no delay compared with the communications between community pharmacy and GPs elsewhere.

I participate in efficiency saving as well, deleting obsolete drugs from repeat reorder lists and making changes, for example Clenil to Soprobec, because I can get it cheaper. But we're not motivated by money - for our team it’s clinical effectiveness and best practice  that we’re motivated by. We aim for the best for the patient.

We are just on the border with England and we have patients across four different health boards – Borders, Dumfries & Galloway, Northumberland and Cumbria. So technically you can get recommendation from different hospital using four different formularies.

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

We are a small, close-knit team and communicate very well with each other. Every team member is treated equally no matter what role they play.

We frequently liaise with neighbouring community pharmacies, the nearest of which is Langholm, which is 12 miles on a single-track road and we only have a limited bus service. If one of our patients is on holiday and has forgotten their medicines we’re able to get in touch with the nearest community pharmacy and send the prescription. If we’ve got real supply problems then I know community pharmacies that can help. But we’re so isolated, we have to be creative.

We’re also quite a popular holiday destination, so we get quite a few people coming in as temporary residents who have forgotten their medicines, and we’re able to sort that for them.

We are unable to offer the minor ailment scheme because we’re not a community pharmacy. There are other services that community pharmacy gets paid for, but we miss out because we don’t come under the community pharmacy umbrella.

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

Isolation definitely, and we have an ageing population. People come here as a nice place to retire. Patients can have a 30-mile round trip to come and pick up their prescription. We don’t offer a regular delivery service to everyone because logistically it would be hard as we have a 15-mile radius of patients. It’s not like in the city where you can pop round with your deliveries. The GPs doing house visits can often just drop the medicines off, but that’s not sustainable. This is an organisational problem for the future, especially with the aging population.

We’ve got a really good ‘home care’ setup locally with two companies that look after people in their own homes and a joined-up system of doing their medicines on MAR charts. If the GP changes the medication, we can quickly and efficiently change their medicine and chart that same day.

But the rurality makes it hard and we probably prescribe more Calpol and antihistamines than a city practice, because patients don’t have the same access to a range of ‘over-the-counter’ medicines.

One of the problems, because it’s a wee village and we all live and work here, is that often one of us will get stopped by someone on the street saying, ‘can you help me this medicine or problem’? Sometimes we are a bit too accessible.

Are you currently undertaking any training? 

I continue to access training in anything related to COPD or asthma. I’ve done my IP; it’s just trying to keep up to date. I am reducing my hours to part-time and I guess I’m looking to retirement, but I still want to stay involved as it is such a rewarding and fulfilling job.

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?

A long time ago, we had someone wanting to open a community pharmacy in our village. I don’t think it would be financially viable for them. We wouldn’t employ another pharmacist because we don’t need a pharmacist full-time. I wonder what the future skills mix is going to look like. Another factor is the limited numbers of GPs looking to work in a practice like ours. It is about delegating to appropriates staff, including advanced nurse practitioners and practice nurses.

Being a rural dispensing doctors’ surgery, we’re not realistically going to get another pharmacist wanting to come and work two days a week here. For the future, we need to work out the skills mix and shortages. I know the Borders team are doing prescribing support but a lot of that is remote, there’s quite a lot of drive to access practices remotely. We have really qualified, skilled technicians doing this work.

Because we’re here, we know the whole clinical background and the patient’s story, whereas in a community pharmacy you will know that someone is on levothyroxine, but you don’t know their recent thyroid function tests and what else is going on. The clinical check cannot be done completely with the limited information community pharmacy has, and it would be great if there were more joined-up electronic records.

We have that extra knowledge of our patients to individualise medicines. I think it’s moving in the direction of non-individualised or personalised medicine because of the lack of staff and the workload. I worry what the future is for here and for other practices.

What do you like to do in your time off?

Spend time with my family, walks and cycles and runs. There’s so much here on our doorstep in our village.

Read more from our Pharmacist in Practice series.