Dr Peter Scriven, GP and divisional director, and Jo Lacey, divisional manager, Royal Primary Care, describe how they have developed the role of pharmacy technicians to support medicines management at their Trust-led group of GP practices.
Royal Primary Care (RPC) is a large-scale provider of general practice services to around 45,000 patients in Chesterfield and Clay Cross, Derbyshire through a mix of APMS and PMS contracts. It forms the primary care arm of Chesterfield Royal Hospital NHS Foundation Trust (CRH NHSFT).
RPC operates three GP practices at eight sites across a catchment of 46 square miles. The practice population is predominantly from deprived socioeconomic groups: 53% of Chesterfield’s most deprived population are patients at RPC, and 63% of patients have one or more long-term condition compared with an average of 56% locally and 51% nationally. The practice was rated Good by the Care Quality Commission in 2019.
RPC has a large multi-disciplinary clinical team made up of GPs, advanced nurse practitioners, specialist mental health practitioners and clinical pharmacists (four whole-time equivalent [WTE] posts) and pharmacy technicians (three WTE posts). There is an integrated training programme for pre-registration pharmacists overseen by the Pharmacy Department at CRH NHSFT. The pharmacy team is employed by the hospital as it was felt this would provide optimal professional support, and develop a workforce that could work flexibly across both primary and secondary care.
RPC has been using clinical pharmacists since 2017 to support GPs and others in the safe and effective management of medicines. Pharmacy technicians were brought on board in 2018 after a modelling exercise to optimise the pharmacy team, to free up clinical pharmacists for great involvement in patients’ clinical care. We would like to see pharmacists undertaking more direct patient contact in key areas of clinical priority such as chronic pain management, de-prescribing and minor ailment clinics, and medicines optimisation in patients with long-term conditions such as heart failure.
RPC operates a philosophy of the ‘right care, right clinician, right time’. The key to delivering this is to ensure that all roles within the multidisciplinary clinical team are available to focus time and resources on the aspects of care that they are best suited to provide.
The volume of tasks relating to the safe prescribing and monitoring of medicines is growing substantially. We supported the development of pharmacy technicians to implement medicines optimisation initiatives across the practice and ensuring that GPs and others can spend more time on patient facing work. Some of the team joined the practice with extensive primary care experience, while others have been trained ‘on the job’.
At RPC technicians are an integral part of the practice pharmacy team, and undertake a wide range of duties relating to the optimisation of medicines. This includes:
Clearly these overlap with some work that clinical pharmacists in the team will also undertake. We have therefore established clear Standard Operating Procedures (SOPs) for the specific aspects that the pharmacy technician will do, within the limits of their competency and depending on experience. Individual clinicians also recognise the limits of their competency and know when to refer/defer to one another. The team is also working on ways to create workstreams in the referral process that will direct tasks to the most appropriate clinicians.
Where shared care protocols or SOPs exist, our pharmacy technicians play a particularly valuable role in ensuring that primary care monitoring requirements such as weight, blood pressure and biochemical and haematological values are fulfilled. Moreover, they are able to carry out dose optimisation for such treatments as DMARDs, thyroxine, and anti-hypertensives.
Examples of care within the technician’s competence would be: using a high-risk medication template to issue a repeat prescription of methotrexate for the GP to sign; or performing medication review at a patient’s long-term condition review, coding and re-authorising a prescription.
By contrast, work beyond the technician’s competence that a pharmacist would need to undertake might include reviewing a patient’s medication regime where side effects or tolerability are a concern, and adjusting a dose or prescribing alternatives, or deprescribing.
The practice group has seen improvements in markers of medicines optimisation and in terms of freeing up clinician time. The reconciliation of medicines following discharge from hospital has been completed more efficiently with resultant improvements in the accuracy of repeat prescribing records. The governance of prescribing for medicines requiring regular monitoring has been improved to comply with local guidelines.
The input from pharmacy technicians has helped to create a more dynamic pharmacy team to deal with the rising volume of prescribing related tasks and increasing problems with medicines supplies. Although we do not yet have quantifiable data on this yet, we believe this is helping the organisation as a whole to prescribe more optimally and freeing up clinician time for patient facing activity.
The RPC-CRH NHS FT relationship allows trainee pharmacists and pharmacy technicians to experience primary care and understand the positive impact these professionals can make to a large patient population.
Our main challenge has been in ensuring that the rest of the primary care team understands what the pharmacy technician can do. There is a tendency for the pharmacy team to be seen as a generic support team, rather than comprising two separate professional groups.
It is important for the wider clinical team and non-clinical colleagues to understand the distinction so they know what tasks technicians can help with, and which need to be referred for pharmacist input. The pharmacy team has been reviewing how to overcome this and is working on a ‘guide’ for practice staff to better explain how the respective roles of technicians and pharmacists can be distinguished.
We have been very pleased with the contribution that our pharmacy technicians have made to the practice in supporting the best use of medicine and are very aware that they could contribute more. We plan to do some more work across RPC to help all of our staff become more familiar with their skills and knowledge.
Hannah Goodchild is an experienced pharmacy technician who has worked at RPC since 2018. She believes that the role could be expanded further in support of GPs and the wider team: ‘Our training in the supply of medicines means that technicians are very good at bringing a logical and structured approach to our work. This has obvious benefits when it comes to tasks such as medicine reconciliation and medication review.
‘There is undoubtedly more that we can do, particularly relating to the education of patients and supporting them to get the best outcomes from their medicines.’
Hannah has also been leading on the development of a workload ‘dashboard’ to provide the pharmacy team and the wider GP practice team with an indication of trends in workload. Data extracted from the practice system is being used to track medication review performance, along with numbers of ‘tasks’ that are being directed to the team. This can be analysed at locality and practitioner level and is helping to inform discussions regarding demand and capacity, and in particular how work can be directed to the most appropriate individuals – ie, technicians or pharmacists.
Dr Peter Scriven is a GP and Divisional Director at Royal Primary Care; Jo Lacey is Divisional Management Director, Royal Primary Care
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