Community pharmacy: a pill for primary care

Accident and Emergency Departments are backing up, GPs cannot cope with their workload, ‘out-of-hours’ services are unsatisfactory: looks like it is time to invent a new service.

Shall we start with accessibility? Let’s say that we have drop in centres open 60-100 hours a week, so weekends and evenings are covered. Patients don’t want to wait for a consultation, so let’s set the average waiting time as, say, three minutes. That is not the time to see a receptionist, but the time to see an expert – someone registered with a national body committed to ensuring and improving competence. Finally, the expert should not only be able to diagnose but also to treat.

Ta dah! It already exists: community pharmacy.

So why are community pharmacy activities not integrated into the rest of the patient’s care? There have been various forms of minor ailments schemes in some community pharmacies, financially supported by the NHS to varying extents, but this care has not been integrated into the patient’s GP record.

Even in Scotland (in the international vanguard of community pharmacy development, where patients with a chronic condition can be registered with a pharmacy to receive pharmaceutical care), there is still work to be done to link a record of the pharmacist’s activities with those of the GP. In hospitals, pharmacists have been reading patient records for decades and are able to contribute to them – why not in primary care?

In my other role as Professor of the Practice of Pharmacy at UCL School of Pharmacy, I had the privilege of spending part of last year with Dr Hamish Wilson considering the future of pharmaceutical care in Scotland. The report is with the Scottish Government and likely to be published this summer.

I was particularly impressed with a service from a pharmacy that stayed open late, with a prescribing pharmacist available to diagnose and treat patients who dropped in. Surely this sort of service meets patient need and makes the best use of available resources?

While we can get better at integrating community pharmacists into the formal care of patients, making them part of a distributed team to support patients’ needs, there are challenges.

Pharmacists are already part of the clinical team in hospitals these days, however I remember being a hospital pharmacist in London in the early 1980s. I spent part of my time as a trainer and the most popular course I ran was ‘Dealing with aggression’ – from the doctors more than from the patients.

It took years for pharmacists to improve their skills and judgment and win the trust of doctors, however they have done so very successfully. Now many junior doctors are trained in prescribing by hospital pharmacists. A few weeks ago I spoke at a conference in Cardiff on inter-professional learning between the two professions. There was a wonderful atmosphere and many examples of integration at undergraduate and postgraduate levels.

The only area where pharmacists and doctors are not usually working as a team is in primary care, and this is neither in the patient’s interests nor that of the NHS.

I am not underestimating the complexities of the task: there are structural barriers – the need for linked information systems; the problem of community pharmacists being legally required to be in the pharmacy while it is open; GPs being unsure how to relate to several competing community pharmacies in their patch, and so on. However these are not the key barriers.

The key to collaborative working is trust. If GPs don’t trust pharmacists (and, to a certain extent, vice versa), then nothing will happen. This lack of trust was present in the early days of clinical pharmacy in hospitals – trust built up slowly from collaboration between innovators in both professions.

Now we need to build trust in simple stages in primary care. Pharmacists could improve their consultancy skills by learning diagnostic and treatment skills from their local GPs – think of the number of childrens’ ears they could look into if appropriately trained and then provide simple treatments, relieving some of the pressure on GP services.

There could be agreed guidelines for referral onwards, and the sort of information the GPs wanted to know could go onto the patient record. This communication can be linked with other areas of interaction – such as how to link in the New Medicines Service or the chronic medication service in Scotland.

So let’s get them talking – it can deliver benefits for the GPs, the pharmacists and, most of all, the patients.

Nick is Director of Research at the Health Foundation and Professor of the Practice of Pharmacy at UCL School of Pharmacy.