Collaborative working with GPs to enable pharmacist prescribing

In Pharmacy CPD Modules

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Authors: Dr Asifa Akhtar, GP partner and clinical supervisor; Emma Anderson, pharmacist independent prescriber

Closer joint working between community pharmacies and GP practices in a locality benefits patients, GPs and pharmacists. It enables pharmacists to use their skill sets – including independent prescribing – within multidisciplinary teams.

This CPD module explores these benefits and uses Kotter’s 8-stage change model as a road map for service development. As independent prescribing for common conditions has been announced in the new Community Pharmacy Contractual Framework for England, the module identifies advanced and prescribing services that would benefit from joint working.

Using a real-life example, it discusses how Village Health Group, comprising four GP surgeries in the East Midlands, has worked with local pharmacies to support choices around access to care for on-the-day illness. Collaboration started with the Pharmacy First service and gradually extended to include community pharmacist prescribing in response to the many patients excluded by the PGDs.

The module gives perspectives on how joint working can happen in practice, shares what has worked well, and describes challenges encountered and how they were overcome.

It asks you to consider the strengths, weaknesses, opportunities and threats surrounding collaborative working between GP practices and community pharmacies in your locality using a standard SWOT analysis. You will then be able to develop a communication plan for a joint meeting with local GP practices to explore service development opportunities.

The module draws on real-life experience from Dr Asifa Akhtar (AA), GP partner and IP pathfinder clinical supervisor at Village Health Group, and Emma Anderson (EA), pharmacist independent prescriber and clinical services director at Evans Pharmacy in East Leake, Nottinghamshire.

1. Create shared vision and sense of urgency

The first step in any collaborative working exercise is to take stock and consider your current relationship with local GP practices and other pharmacies, alongside the services you currently provide – then to consider how prescribing could add to this offer and improve patient care.

In this section, we consider the benefits of collaborative working for patients, GPs and pharmacists. Consider how you can communicate these benefits concisely to each group.

Scotland and Wales have already introduced community pharmacy independent prescribing into their on-the-day illness services and aim to have a pharmacist independent prescriber in every community pharmacy by 2030. The 10-Year Health Plan for England also aims to introduce an NHS community pharmacy independent prescribing service.

This offers opportunities for community pharmacists to make best use of their clinical skill sets and gives patients greater choice, avoiding PGD exclusions that can seem arbitrary, such as being a few days too old or too young for a service.

The new GP contract in England explicitly requires that requests identified as clinically urgent by the GP practice must be dealt with on the same day. Doctors therefore benefit from referring patients to a pharmacy of the patient’s choosing, as this helps maximise appointment availability within the practice. Pharmacy professionals benefit from being able to use their skill sets within a multidisciplinary team, and contractors benefit from service fees.

Success from joint working involving advanced PGD-based NHS services can be built upon through prescribing as this increases pharmacists’ flexibility to treat a wider range of conditions and more patients. We describe the collaborative work we have undertaken through advanced services and the independent prescribing (IP) pathfinder programme in Panel 1.

2. Build guiding coalition and arrange initial conversation

Your next step is to build a ‘guiding coalition’. In our example, the initial meeting included LPC staff, EA (a former community pharmacy PCN lead), a GP partner and the ICB to discuss joint working over PGD services.

A key point discussed was how to manage patients excluded from PGDs without requiring them to return to the start of their GP triage. The aims were to make better use of local skills and ensure a more positive patient experience.

Initially, these excluded patients were treated by the duty GP immediately after their pharmacist consultation.

After becoming an IP pathfinder site, more patients could be managed in the pharmacy, with GPs still available for guidance and advice.

It is essential to decide your top-line messages and be prepared to provide detail if the other person wants it. Read their body language as well as listening to their words.

Come prepared with the range of NHS services you can offer, the number of slots available at your pharmacy, and how this could potentially be scaled to include other community pharmacies. Keep the message about your offer concise and easy to remember for both your own team and GP practice staff.

Agree next steps. Once a service has been implemented, decide on a review day to resolve minor issues that can occur when processes are introduced.

3. Form a strategic vision

At the initial meeting, you will want to begin determining your strategic vision and identifying pharmacy services that present opportunities for joint working based on that vision. In our case, we chose to start with PGD-based on-the-day illness services and use this as a foundation on which to build a prescribing element. This was driven by a desire to optimise choices for on-the-day illness.

Consider what services might lend themselves to collaborative working with GPs in your locality.

4. Enlist a volunteer army

Our ‘volunteer army’ were community pharmacists who were prepared to accept GP referrals. The GP contract in England requires patients to be given a choice about which pharmacy they are referred to, and each pharmacy can only treat a certain number of patients each day.

Achieving a consistent local offer is therefore key. In the past, different community pharmacies and GP practices often worked in competition, whereas now there are advantages for everyone in collaborating.

A key opportunity is to consider how you can work together to provide access. If appointment slots at your pharmacy are taken on a particular day, how can you quickly identify other local providers who could see that person before you signpost them?

Initially, EA, as community pharmacy PCN lead, phoned pharmacies and offered to visit to explain the benefits she had realised from joint working and to offer support if useful. The GP practice then formally contacted pharmacies to arrange joint visits.

AA comments: “We work with a range of local pharmacies, including those further away if the patient chooses them. It is helpful if pharmacy providers collaborate to provide a consistent local offer, so it is useful to work at scale. The more appointments you can offer GP practices, the better. Going into double figures daily for the number of available appointments is ideal. We can never have enough.”

5. Enable action, remove barriers

It is vital to consistently offer all available services and clearly explain what you can prescribe. While pharmacists are keen to focus on prescribing and the clinical aspects of care, it is crucial to acknowledge and address local GP practice frustrations about lack of consistency in existing service offers.

The NHS Pharmacy Contraception Service, particularly emergency contraception, is one example where accommodating extra patients, when this can be done safely, can go a long way towards building good multidisciplinary relationships.

It is important to clearly explain to local GP practices and patients which services you can offer. Give top-line information and then offer more detail if the practice/person wants it.

Difficulties with joint working often arise because either the patient or GP does not understand what is available from pharmacies. Prescribing may simplify the offer by excluding fewer patients from services, particularly for on-the-day illness, and this should be emphasised.

GP practices often have triage systems that refer patients to different clinicians. AA suggests: “It is worthwhile working with GP practices to let 

them know what capacity you have to see patients each day, and which services are available in your pharmacy on any given day.”

This includes both advanced services and the availability of any extended services: “If you have a pharmacist IP with an extended scope of practice working in your pharmacy who can, for example, treat adult ear pain or chest infections, it is useful to know this,” AA says. “It is helpful to discuss the best way to refer patients into the service and how to communicate referrals.”

6. Generate easy wins

Add value when you refer by documenting appropriately and agree methods for timely information transfer. A challenge can be managing situations where the patient’s needs are outside the scope of a service or indeed your own competence. Community pharmacists have often worked in isolation and, as a result, it can be tempting to think, “either I need to solve this problem in its entirety or I cannot get involved”.

A top tip is to think about how you as a pharmacist can add value. For example, could you document a history, report observations such as blood pressure, capillary refill time in children, heart rate, oxygen saturations and respiratory rate, and record examination findings, such as those shown in Table 2.

When you have written clear notes, consider how these can be communicated and acted upon in a timely manner. Increasingly, requests to GP practices can be made via website portals, so check what works best in your locality. From a practice perspective, it can be difficult if many issues are escalated later in the day, so timely communication is key.

7. Increase the pace 

This is a good point at which to consider other services. It may be that you have effective joint working for NHS PGD-based services and are now starting to consider NHS prescribing.

In our case, increasing the pace involved looking at contraceptive pill checks as an available NHS service that was not being fully utilised as our next opportunity for joint working. Think about the benefits other services would bring and what is available in your locality.

8. Measure success

What will success look like for you and those whom you collaborate with? How will you document evidence to evaluate your service?

EA calculated the percentage of patients who had to be referred from her prescribing and Pharmacy First consultations. This proved to be a powerful tool. “Initially, for me, a goal was to prove that we were referring appropriately, as it was important to patients that I could provide end-to-end care when it was safe to do so.”

“A key measure of success was that the number of patients referred to the GP practice from my prescribing consultations was less than half of that from Pharmacy First, while treating a wider range of conditions. Alongside numerical data, I collected qualitative data on the reasons for referrals. Feedback from GPs and pharmacists involved in the IP pathfinder agreed that the referrals were made for sensible reasons.”

AA and colleagues found the data valuable and reassuring: “Knowing that the percentage of patients referred back to us from pharmacy services is low and appropriate is important. It is also good for pharmacists to be able to feed back to GP practices why they cannot treat a patient themselves. Systems should be developed so that patients whom the pharmacist cannot treat do not need to enter the system again, as this gives a much more positive experience.”

Recognising that some patients need to be referred, AA points out how pharmacists can add value: “It is helpful to give a clear and accurate history and observations, as well as any examination findings and points of concern.”

Patients’ experience of any integrated pharmacy service is key, says AA: “It is important that the patient has a positive experience. This means being seen in a timely manner and given flexible appointment choices. Patients should be treated by a confident clinician who builds a positive relationship with them. This means the patient is more likely to use the pharmacy service again.”