Clinical Pharmacists in General Practice: Pilot scheme

Transcription

1 Clinical Pharmacists in General Practice: Pilt scheme Independent Evaluatin Reprt: Full Reprt June 2018 Authred by Dr. Claire Mann, Prf. Claire Andersn, Prf. Anthny J. Avery, Prf. Justin Waring and Dr Matthew J. Byd. The University f Nttingham Funded by NHS England

2 Cntents Acknwledgements... 4 Intrductin... 5 Scheme utline... 5 Methds... 6 Intrductin and verview... 6 Breakdwn f stages f research... 8 Rutine service data... 9 External stakehlder cnsultatin... 9 Audit Survey f scheme participants Qualitative data Data analysis Reprting and disseminatin Literature review UK primary care cntext What is the impact f pharmacists in general practice n patients health utcmes? What is the patient perspective n pharmacists wrking in GP practices? What is the general practitiner perspective n clinical pharmacists wrking in GP practices? What is the pharmacist perspective n clinical pharmacists wrking in GP practices? What are the barriers preventing successful implementatin f this rle? What are the facilitatrs t ensure successful implementatin f this rle? Findings respnses t the research questins Intrductin The rle and activities undertaken Practice staff perspective and sustainability What is the general practitiner perspective n clinical pharmacists wrking in GP practices?.. 20 What is the site lead perspective n clinical pharmacists wrking in GP practices? What is the MDT perspective n clinical pharmacists wrking in GP practices? Summary Identify csts and effect f the Clinical Pharmacist rle Cst Effect Return n investment Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 1

3 Develping and capturing cst and effect Facilitatrs and barriers What are the barriers preventing successful implementatin f this rle? What are the facilitatrs t ensure successful implementatin f the CP rle? Cllabrative wrking Strengths and limitatins f the wrk Cnclusin Summary f recmmendatins References Appendix A Example f lcal data cllectin by a pilt site Appendix B Rutine service data Data cllectin Observatins f the evaluatin team with regard t rutine service data Summary f rutine service data prvided t evaluatin team Summary Appendix C Natinal survey f pilt sites Audit data Survey findings Clinical pharmacist participants Pilt site lead participants Clleagues participants Summary Appendix D External stakehlder perspectives - Overview f SWOT data Intrductin External stakehlders Strengths Weaknesses Opprtunities Threats Summary Appendix E - Case studies Case Study Overview Case Study A Backgrund (Site and Staff) Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 2

4 Cnceptualisatin Implementatin Operatinalisatin Outcmes KPIs Case Study B Backgrund (site and staff) Cnceptualisatin Implementatin Operatinalisatin Outcmes The future Case Study C Backgrund (site and staff) Implementatin Operatinalisatin Outcmes Uniquity The Future Summary Appendix F Qualitative thematic analysis Intrductin Overview Participants Summary table f participants fr in-depth interviews Site Leads GPs Pharmacists Patients Terminlgy Cnceptualisatin Planning and applicatin Ratis Turnver Cnceptualisatin summary Implementatin GP Expectatins and assumptins Inductin Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 3

5 Mentring Training Educatin Implementatin summary Operatinalisatin (The Day Jb) Activities Clleagues and relatinships Rle develpment Changes in primary care practice The multi-disciplinary team mix Operatinalisatin summary Outcmes Capacity Quality Uniquity Safety KPIs Sustainability Outcmes summary Patient stries Appendix G Glssary and abbreviatins Acknwledgements The prject team wish t express their gratitude t Dr Chris Freeman (University f Queensland, Australia) and Dr Helen Bardman (University f Nttingham) fr their cntributins and advice t the prject team. Mr Antny Chuter, patient representative, fr his challenging crss examinatin and guidance in prject meetings. The staff and students f the University f Nttingham Divisin f Pharmacy Practice and Plicy fr their assistance with data acquisitin and analysis. Mrs Lraine Buck fr her administrative and extensive transcribing supprt and the NHS England Clinical Pharmacists Wrking Grup fr their directin. The evaluatin team are grateful t all thse wh tk the time t cntribute t this evaluatin. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 4

6 Intrductin This reprt presents an verview f the requested research questins and hw they were answered including a review f current literature, methds, breakdwn f data by type and an verview f the findings respnding t the research questins. This is fllwed by appendices (A-F) f underpinning data by type and includes in depth case study data (Appendix E). This evaluatin aims t prvide an verview f the Phase 1 Pilt t integrate clinical pharmacists int general practice and identifies hw best t implement and evaluate the final rll ut. Within this prcess we identify the ptential impact f the clinical pharmacists, describe hw they are likely t affect wrking practices and hw they may imprve service delivery related t medicines bth within the medical practice and externally with Clinical Cmmissining Grups (CCGs), cmmunity pharmacy and hspital pharmacy. The bjectives f this evaluatin were t: Describe a range f activities undertaken by clinical pharmacists and their perceived impact n medicines ptimisatin Describe medical practice staff satisfactin with the innvatin and likelihd f cntinuatin beynd pilt phase Identify the ptential csts and effects f clinical pharmacists wrking in general practice frm an NHS perspective e.g. GP and practice staff wrklad, medicines and mnitring csts and use f secndary care services such as emergency and urgent care Identify and describe the barriers and facilitatrs assciated with their effective integratin and delivery f rle and service Develp and test a generic mdel f effectively capturing the csts and effects f clinical pharmacist delivered services Identify and describe activities undertaken t enhance cllabrative wrking between hspital pharmacy, cmmunity pharmacy and general practice t imprve service delivery and patient care A review f current academic literature was necessary t grund the research in the current knwledge in the field. Scheme utline The General Practice Frward View (GPFV, NHS England, 2016) utlined the measures that NHS England (NHS England) are taking t develp general practice. The reprt suggests that a range f healthcare prfessinals can becme an integral part f the practice team, in much the same way as nurses have and emphasises the inclusin f pharmacists t cntribute t patient care. Pharmacists remain ne f the mst underutilised prfessinal resurces in the system and we must bring their cnsiderable skills in t play mre fully. (NHS England, 2016) The GPFV utlined an investment f 31millin t pilt 470 clinical pharmacists in ver 700 practices. This is t be supplemented by new central investment f 112 millin t extend the prgramme. This Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 5

7 will result in ver 2000 clinical pharmacists in general practice by 2020, a rati f ne clinical pharmacist per 30,000 patients. (NHS England, 2016) NHS England funded this ne year evaluatin f the initial pilt phase f the Clinical Pharmacists in GP Practices scheme. The Clinical Pharmacists in GP Practices scheme was launched as a pilt scheme in , with further rllut phases. NHS England reprts that in February 2017 the pilt scheme had funded 89 applicatins frm federatins wh in turn recruited ver 490 pharmacists (greater than 450 whle time equivalent (WTE)) t wrk acrss mre than 650 GP practices. (Sharma, 2018) The first scheme was launched as a pilt phase and there are sme minr differences between this initial pilt scheme and later iteratins. Mst ntable differences between the peratinalisatin f the pilt scheme (phase 1) and the next iteratin (phase 2) are imprvements in the management f the scheme with a clear clinical leadership rle, clearly defined ratis fr sites and mentring, and a changed apprach t reprting KPIs. Each site applicatin was at a level f scale, including a grup f GP practices r ther sites, referred t as a federatin site. At each federatin site a nminated persn led the bid, and develped the scheme lcally. The bids were assessed by reginal teams. In the pilt, practices culd apply fr 60% f csts in year 1, 40% in year 2 and 20% in year 3. Practices were required t meet the remaining csts themselves, althugh sme CCGs have put in additinal funding as well t reduce the initial amunt payable by practices. Sme additinal funding is prvided n a case by case basis twards the management f the scheme. Over the curse f the 3 year funded implementatin perid it is envisaged that practices will recgnise the value f the wrk dne by the pharmacists and cver the full cst f their emplyment. Health Educatin England (HEE) prcured the educatin and training prgramme which was delivered by the Centre fr Pharmacy Pstgraduate Training (CPPE) fr pharmacists in this pilt wave, sme in cnjunctin with Red Whale, anther training prvider. Further funding and time in the scheme is dedicated t upskilling clinical pharmacists withut existing qualificatins t becme independent prescribers. Independent prescribing training is undertaken at lcal higher educatin institutins with underpinning mentring prvided by practices. Methds Intrductin and verview The research tk a mixed methds apprach t understanding the scheme implementatin. The evaluatin wrked t a very tight budget and schedule and ptimisatin decisins were taken t maximise data cllectin. All areas prpsed fr evaluatin were included, alngside additinal iterative methds. This sectin utlines the research apprach and the way data was cllected and analysed in this pilt evaluatin. The fllwing diagram utlines the data cllectin appraches utilised in this shrt pilt evaluatin study. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 6

8 Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 7

9 Breakdwn f stages f research Table 1 utlines the data cllectin appraches utilised and numbers f key participants at each phase. Type N= Date Rutine Service Data (Mnthly spreadsheet cmpleted n a per site basis) 12 Practices Data prvided t September 2017 SWOT External stakehlder cnsultatin Questinnaires n=33 (40%) Fcus Grups n = 4 (31) 4 th July 2017 Audit Tracking f sites returned NHS England data Site 89 CPs 491 Audit data Site 77 CPs 379 July and August 2017 Questinnaires Sites 68% CPs 40% Site leads n=52 (ver 41 sites) September and Octber 2017 Clleagues (including GPs) n=63 CPs n =159 Qualitative Data Case study site visits N=3 Octber 2017 January 2018 Site Lead interviews N=7 GP Interviews N=4 Pharmacist Interviews N=7 Patient Interviews N=17 (3 Fcus grups) Table 1: Data cllectin phases Each phase f the data cllectin was delayed due t unanticipated bstacles. Ntwithstanding this, an enrmus amunt f multimdal data was cllected t infrm the research in this reprt. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 8

10 Rutine service data The research team were prvided with the mnthly return data fr 12 practices up t August The purpse f this was t describe basic pharmacist activity. Data were extracted frm the prvided spreadsheets and analysed using descriptive statistics using Micrsft Excel Data prvided was nt always cmplete and was a very small percentage f the ptential return available. Data was submitted t NHS England by sites via making data extractin mre challenging. External stakehlder cnsultatin The research cmmissined was t engage with stakehlders invlved in the pilt phase f the Clinical Pharmacists in general practice scheme. Data cllectin methds were bth planned and emergent, in rder t respnd t arising circumstances. The stakehlder day rganised by Health Educatin England (HEE) in July 2017 ffered a unique emergent pprtunity fr the research team t engage with key stakehlders frm the pilt scheme and gather research data. Stakehlders attending the day represented a wide range f gegraphic as well as jb rle and level diversity. Attendees (n=80) included bth n the grund rles such as CPs in the rle, pharmacists in a range f wider rles, GPs and pilt site leads, as well as representatives frm mre strategic stakehlders representing rganisatins such as gvernment, universities, Ryal Pharmaceutical Sciety (RPS), Centre fr Pharmacy Pstgraduate Educatin (CPPE), HEE, Ryal Cllege f General Practitiners (RCGP) and thers. Tw key data cllectin methds were used t generate feedback frm key stakehlders n the scheme s far. Bth methds utilised a SWOT (Strengths, Weaknesses, Opprtunities and Threats) analysis apprach t ensure representatin frm all areas f the. This is a technique previusly utilised successfully in a range f studies. (Helms and Nixn, 2010, Jacksn et al., 2003, Picktn and Wright, 1998) The first methd invlved the cmpletin f a paper based SWOT analysis, asking stakehlders t respnd t these key areas relating t the scheme at three levels patient, practice and plicy. The paper based exercise was distributed t all stakehlders attending the event early in the day and cllected at the end. Thirty three cmpleted SWOT analyses were cllected representing 40% f participants. Data was cllected in a database, analysed thematically and tp level findings are presented in full in tabular frmat in the reprt. (Appendix D) The secnd methd invlved stakehlders attending fcus grup interviews facilitated by the research team t discuss stakehlder views n the SWOT f the pilt scheme. The ttal number f interview participants was 31, split int 4 grups f similar sizes. Fcus grup participants included participants frm bth n the grund and strategic rles. Data was recrded and transcribed verbatim and analysed accrding t the SWOT framewrk. Data was subject t cllabrative emergent thematic analysis. (Appendices D & F) Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 9

11 Audit NHS England were unable t prvide the evaluatin team with an up t date list f clinical pharmacists in pst as this infrmatin was nt rutinely captured by NHS England fr this Pilt wave, the nly recrds held were at the level f the site that cmpleted the initial applicatin. The training prvider CPPE was als nt able t share an up t date cmplete list f clinical pharmacists as training was prvided n an pt-in basis and included pharmacists nt n the pilt. Frm the riginal applicatin data and CPPE training registers, NHS England believed that the plt wave cnsisted f: 89 applicatin sites 451 CPs WTE emplyed (491 psts) 58 GP practices acting as hsts t GP Pharmacists In rder t facilitate an nline survey and track respnse rates it became vital t cnduct an audit which culd clarify the numbers f sites and emplyees and establish a line f nline cmmunicatin. An audit tk place ver June-September Each pilt applicatin site was cntacted by and asked t cnfirm their participatin in the pilt and prvide the names and addresses f the clinical pharmacists and the GP practices wrked at. A first request fr infrmatin was sent in June with fllw up s in July. In the event f nn-respnse, a series f telephne calls t the site were placed t establish this infrmatin. Supprtive s frm NHS England in August asking that sites participate in the evaluatin were helpful. We were able t cnfirm data fr 78 ut f the 89 prpsed applicatin sites. 9 sites chse nt t respnd t the multiple requests fr audit data. (2 respnded after the survey had been clsed, and the thers chse nt t be invlved) 2 sites were fund t be duplicate sites. 1 site infrmed us that they did nt prgress with the scheme. We were able t cnfirm, frm the 78 sites wh engaged with the audit prcess, a list f 373 pharmacists wh were emplyed n the pilt scheme. We were als made aware f where there were vacant psts. Survey f scheme participants The research team cllabratively designed the cntent f the survey/s based n the riginal research questins submitted in the evaluatin tender bid and issues emerging frm the current published literature in the field. Whilst the riginal study design had been t survey nly clinical pharmacists and their clleagues in the practice, an imprtant new categry f participants emerged frm cnducting the audit. The pilt site leads wh were cntacted fr the infrmatin abut clinical pharmacists were sharing valuable infrmatin abut the scheme and clearly played an imprtant rle in its implementatin. It was therefre decided t iteratively develp a survey fr this new categry f clleagues wh emerged as significant gatekeepers t the scheme, the clinical pharmacist and therefre the evaluatin research. Each iteratin f the questinnaire was pilted bth internally with the steering grup, and externally with a lcal sample f Pharmacists. Adjustments were made ver 5 runds f amendments t incrprate changes t face and cntent validity. The platfrm fr the nline survey was Bristl Online Surveys (BOS), as this platfrm meets all data prtectin and lcal ethical requirements. Unfrtunately the ethical requirements t use this platfrm were prblematic since the platfrm mved hsts (University f Bristl t JISC) during the perid f the survey administratin withut prir knwledge t the team. This caused bth a delay t the survey and a disruptin during the survey perid that may have had a negative impact n respnse rates. The final versin questinnaire was distributed by n 27 th September, remained pen fr three weeks and clsed n 18 th Octber. All CPs and pilt site leads were sent a persnalised ed a Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 10

12 unique participant link t their respective surveys t allw cmpletin tracking. CPs were als sent a further link t distribute t clleagues wh wrked with them. Tw reminders were sent t nnrespnders. Survey respnses were received frm 52 Pilt site leads acrss 41 sites (sme sites shared their link) this represents a 46% respnse rate at Federatin (site) level. It was nt pssible t identify a single respnse that culd be taken t represent the multi-cmpletin sites. Data were therefre taken as prima facie withut exclusin. 159 CPs this represents a 42% respnse rate at an individual level Of the respnses by CPs, 30% were frm Senir (band 8) CPs and 70% were frm (band 7) CPs Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 11

13 Qualitative data The survey generated a number f sites willing t engage further with the research; this was a much higher number f ptential participants than anticipated. 65% f pilt site leads, 54% f pharmacists and 22% f clleagues (wh returned survey data) expressed willingness t engage with further research interviews. A perid f site engagement and intensive qualitative data cllectin was designed t explre data at an experiential level and maximise this pprtunity. 16 in-depth individual qualitative interviews were undertaken with a varied range f participants, alng with 3 patient fcus grups cmprising a ttal f 17 patients. Thrugh this detailed qualitative wrk, this final reprt is able t present case studies f hw lcal pilt schemes have been peratinalised and the lcal benefits enjyed frm the schemes. These are lcated in the appendices. Three full case studies were undertaken where qualitative interviews were undertaken with pharmacists, practice staff, site leads and patients. Partial case studies were cnducted acrss a further 5 sites. This wide ranging qualitative wrk underpins and triangulates the wider data already cllected n the prject. Data analysis Descriptive statistical analysis was undertaken n the Rutine Service data prvided. It is recmmended that further analysis is undertaken f any further data cllected pst September 2017 and that pilt schemes are jined int a wider centralised data cllectin prcess with later sites. Questinnaire data was subject t descriptive statistical analysis as well as qualitative thematic analysis and raw findings are presented in descriptive frmat. A cllabrative fcused review f SWOT analysis was undertaken t present clear analysis f external stakehlder data. All qualitative data which captured experiential participant perspective data was subject t iterative thematic analysis by prfessinal grup and scheme stage. Where full data exists it is presented in case study frmat t represent cntext-based data. All sites have been cded with letters A-H. Participant s details have been pseudnymised with names beginning with the site letter cde. E.g. Betty cmes frm site B. Reprting and disseminatin Due t the very limited timescale f the evaluatin, prject data has been reprted at the chrt respnse level. This reprt is published as the main utput frm the wrk as an independent evaluatin by the University f Nttingham. Further data analysis and reprting is anticipated thrugh academic peer reviewed jurnals and disseminatin wrk. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 12

14 Literature review A review f current academic literature was undertaken t grund the research in the current knwledge in the field. This theretical knwledge is triangulated with the empirical data cllected t make recmmendatins fr NHS England based n the mst up t date knwledge and data in Pharmacy plicy and practice research at a natinal and glbal level. UK primary care cntext Primary care services, including General Practice, cntinue t face unprecedented and grwing demand. This reflects widely recgnised system pressures assciated with an ageing ppulatin, multimrbidity, plypharmacy. Between 1996 and 2008, GP cnsultatins increased by an estimated 11%, and nurse cnsultatins by 150% (GMC, 2016). At the same time spending n the NHS, and in particular, in general practice in Great Britain has declined (Delitte 2014). Furthermre, there are significant reductins in the numbers entering general practice as a career, and a high rate f turnver f thse wrking in the prfessin. (Baird et al 2016) The General Practice Frward View (GPFV) (NHS England, 2016) recgnises sme f the key issues in efficiently and effectively managing the frntline demand and supply f healthcare in the UK. The Ryal Cllege f General Practitiners (RCGP) suggests ne ptential slutin is t develp a mre diverse skill mix in primary care wrkfrce and utlines the fact that cmmunity pharmacy is a significant unexplited ptential (Gerada and Riley, 2012). In 2013, the Ryal Pharmaceutical Sciety s Nw r Never reprt (Smith et al., 2013) prpsed a significant rethink f the mdels f care thrugh which pharmacy is delivered, twards a mdel utilising the full prfessinal expertise and ptential f pharmacists. The GP wrkfrce 10 pint plan ( NHS England, 2015a) acknwledged that GP practices were recruiting pharmacists and laid ut plans fr the natinal pilt launching in 2015 with the first pharmacists wrking in General Practice n the pilt scheme by 2016 ( NHS England, 2015b) The General Practice Frward View (2016) cmmitted ver 100millin t supprt an extra 1,500 clinical pharmacists t wrk in general practice by 2020/21 as part f a wider expansin f the general practice wrkfrce. What is the impact f pharmacists in general practice n patients health utcmes? A meta-analysis f randmised cntrlled studies fund imprved medicatin cncrdance and reduced ptential medicatin-related prblems in general practices with an integrated pharmacist (Tan, 2014a). The first randmised cntrlled trial f pharmacist prescribing in the UK suggested that there may be a benefit fr patients with chrnic pain.(bruhn, et al. 2014) An Australian study (Freeman et al., 2012a) shws that pharmacists imprve the timeliness and the verall cmpletin rate f medicatin reviews in general practice, the study als cncludes that the time between referral and pharmacist cnsultatin is reduced. The same applies t the time between the pharmacist cnsultatins t GP fllw-up cnsultatin, furthermre mre patients were getting reviewed verall. Pharmacist interventins greatly imprve ACT and CAT scres in asthma and COPD patients, they further reduced the utilizatin f healthcare services and significantly reduce drug cst (Khachi, 2014). Pharmacist cnsultatins can be highly effective in identifying and reslving medicatin related prblems (Tan et al., 2013) the same study als cncludes that the patients welcmed these Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 13

15 cnsultatins and imprved medicatin adherence. Fr high-risk patients with type 2 diabetes mellitus, practive case management by a pharmacist can reduce HbA1c levels f 1.2% cmpared t cntrl in a primary care clinic setting (Che et al., 2005), this reductin in HbA1c levels wuld result in an estimated 40% t 50% relative reductin in micrvascular cmplicatins. Patients that are seen by a pharmacist have a higher chance f their medicatin being changed cmpared t a cntrl grup, althugh the cst f the drug increased in bth grups, the interventin grup was smaller than the cntrl grup. The interventin did nt increase the wrklad f general practitiners but it did nt prve t have decrease the wrklad either (Zermansky et al., 2001). Falls can be significantly reduced in elderly patients in care hmes by clinical pharmacist medicatin reviews cmpared with usual GP care (Zermansky et al., 2006). Pharmacists are able t prvide independent medicatin advice within a primary care setting making this rle t be a simple extensin t their cst saving rle which they already undertake in the GP practice (Chen and Britten, 2000). Pharmacists als prve t be value in management f mre niche cnditins such as insmnia (Sake et al., 2016). In a small Icelandic study (Blndal, 2017a) with 100 patients the pharmacist identified tw drug therapy prblems per patient. The mst frequent prblem was related t nncmpliance, next was adverse drug reactin and the third was unnecessary medicines. Almst all pharmacist interventins were accepted by the general practitiners. This clearly demnstrates that pharmacists practice safe and knwledgeable medicines review which can have clear benefits fr patients health and lifestyle utcmes. Hazen et al s (2017) systematic review investigates hw the degree f integratin f a nn-dispensing pharmacist int a healthcare team impacts medicatin related health utcmes in primary care. Sme pharmacists are fully integrated int the health care team, whereas thers nly temprarily prvide a specific service. Cmmn pinin is that integrated care fr patients with chrnic cnditins may imprve patient utcmes. Pharmacists have been shwn t psitively affect surrgate utcmes, such as bld pressure, glycaemic cntrl and lipid gal attainment. Evidence f the effect f pharmacists n clinical endpints, such as mrtality, hspitalizatins and health related quality f life, is less clear prbably due t very hetergeneusly defined pharmacy activities as well as strngly differing study settings. Mst f the studies did nt include prescribing pharmacists and the authrs acknwledge that this might change health utcmes and needs further study. They als acknwledge that pharmacists perating in islatin may negatively influence the quality f care and that studies highlight the imprtance f cmmunicatin between pharmacists and GPs abut the patients. The authrs cncluded that full integratin adds value t patient-centred pharmacy services, but nt t disease-specific clinical pharmacy services and that t btain maximum benefits f pharmacy services fr patients with multiple medicatins and cmrbidities, full integratin f pharmacists shuld be prmted. The imprtance f pharmacist integratin in a multi-disciplinary team has clear implicatins fr the cntext f this study. Bush et al. (2017) attempted t characterise the breadth and vlume f activity cnducted by clinical pharmacists in general practice in an English Clinical Cmmissining Grup (CCG), and t prvide quantitative estimates f bth the savings in general practitiner (GP) time and the financial savings. This descriptive, retrspective, bservatinal study analysed data cllected by the CCG cncerning the activity f pharmacists in GP practices during This descriptive paper based n rutine data cllectin and relies n self-reprting f activity. Over the 9-mnth perid fr which data were available, the 5.4 whle time equivalent pharmacists perating in GP practices identified 23,172 interventins. 95% per cent f interventins identified reprtedly resulted in savings t the CCG in excess f Hwever, there was n attempt t validate these interventins using fr example an expert clinical panel. During the 4 mnths fr which resurce allcatin data were available, it was reprted that the clinical pharmacists saved 628 GP appintments plus an additinal 647 hurs that GPs currently devte t medicatin review and the management f repeat prescribing. The authrs cnclude that the findings suggest that pharmacists in general practice in the CCG are able t deliver clinical interventins efficiently and in high vlume, generating cnsiderable financial Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 14

16 returns n investment. The CP rle has significant verlap with the CCG pharmacist and share a similar psitin t deliver clinical interventins, in vlume, generating financial return n investment. What is the patient perspective n pharmacists wrking in GP practices? Petty et al. (2003) cnducted extensive research lking int the views f patients n pharmacists cnducting medicatin reviews in a GP setting. They cncluded that nt all patients will benefit frm medicatin reviews as mst patients already have these reviews with their GPs. They fund that sme patients welcmed the mre detailed and lnger review but sme were disappinted by the services as the pharmacists did nt meet their expectatin. Independent prescribing pharmacists are valued by patients as an alternative t GP prescribing in GP practices (Gerard et al., 2012). Hwever, patients in Gerard s et al s study had a strnger preference fr their wn dctr than a prescribing pharmacist. In an Australian study (Freeman et al., 2012a) patients still viewed pharmacists as suppliers f medicines, thugh they welcmed the integratin f pharmacists int GP practice, they als wished fr mre dispensing, therapeutic drug mnitring and supply f ver the cunter medicines. Yunger patients have been fund t be mre likely t welcme the extended rles f pharmacists (Tinelli et al., 2009), including mre willing t have their pharmacist t have bth prescribing and dispensing rles. Tan et al. (2013) in an Australian study cncluded that there were psitive patient attitudes twards pharmacists in primary care and stated that patients were highly satisfied with pharmacist cnsultatins. Green et al. (2016) interviewed seven patients in ne Lndn GP practice and they mstly fund the pharmacist t be experienced and beneficial. The authrs cnclude that as better understanding f the pharmacist s rle might imprve patient uptake. The studies abve were all cnducted befre the NHS England initiative was intrduced, thus the perspectives f patients in UK might have changed as a result f the interventin. Snell et al. (2017) investigated patient views abut a pharmacist led patient-centred plypharmacy medicatin review service cmpleted within 17 English GP practices with thse 75 years f age and prescribed 15 medicatins, during 415 cnsultatins. Of the 40% wh returned the questinnaire, 83% fund the service helpful. Medicatin-related cncerns f 94% were addressed, and 80% understd their medicines better after the review. Patients appreciated pharmacists persnal apprach, advice and explanatins. What is the general practitiner perspective n clinical pharmacists wrking in GP practices? GPs are much mre welcming t the idea f a pharmacist wrking in their practice if the GP has wrked with a pharmacist befre (Bajrek et al., 2015). Bth GPs and pharmacists think that patients wuld accept these new services, they als agree that the initial acceptance by GPs wuld be lw but wuld increase with further expsure (Freeman et al., 2012b). A recent Icelandic actin research study (Blndal et al, 2017b) where pharmacists prvided medicines reviews in either patients hmes, r the GP practice, where they had access t patient recrds, shwed that GPs knwledge abut pharmacist cmpetencies as healthcare prviders and their ptential in patient care increased. GPs said they wanted t have access t a pharmacist n a daily basis. What is the pharmacist perspective n clinical pharmacists wrking in GP practices? Butterwrth et al. (2017) indicated an enthusiasm fr the rle and called fr a definitin f the rle, with examples f the knwledge, skills, and attributes required, t be made available t pharmacists, Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 15

17 primary care teams, and the public. The authrs cnclude that training shuld include clinical skills teaching, set in cntext thrugh expsure t general practice, and delivered mtivatinally by primary care practitiners. Cnsultatins with a pharmacist regarding medicines, in a general practice setting in the UK, have previusly been reprted t be rich in cntent, acceptable t patients, and perceived by pharmacists t be a pssible way t extend their rle (Chen et al., 2000.) A UK analysis f audirecrded cnsultatins abut medicatins, between patients and pharmacists in general practice, cncluded that pharmacists were patient centred, and respnded psitively and effectively t patients emtinal cues and cncerns. The pharmacists in Butterwrths (2017) study recgnised the imprtance f a hlistic, individualised apprach t patientcare and they valued the cmmunicatin skills training n this curse. Canadian pharmacists (Farrell et al, 2008, Pttie, 2009) needed time t expand their knwledge and skills t address family practice needs. They felt their identity changed with time and that they became mre hlistic and less black and white in their apprach pharmacists need t be prepared fr the emtinal challenges f becming part f an interdisciplinary team and need t use integratin strategies t wrk. Mentring and guided integratin activities were helpful t facilitate integratin int family practice but pharmacists still experienced a variety f emtins in the early mnths (Farrell et al 2010). In rder t be successful in gaining patient referrals and feeling part f the team, pharmacists needed t be visible, cmmunicate well and be flexible and innvative. Once they demnstrated their value, they felt that buy-in frm dctrs happened. This qute (Gldman et al. 2010) highlights the uniqueness f the rle and the initial feelings: I m a pharmacist s I knw hw t be a pharmacist. I dn t knw hw t be a pharmacist in a Family Health team because nbdy knws abut that yet. I walked in and I did pharmacy things, but I didn t knw what that meant in relatin t what the nurse des r what the dietitian des. What are the barriers preventing successful implementatin f this rle? Funding is a very clear barrier t implementatin. Depending n whm yu ask, it seems that different stakehlders have different pinins n hw t fund this initiative. (Freeman et al., 2016, Bajrek et al., 2015, Tan et al., 2014b, Sake et al., 2016). Hwever, the current NHS England initiative has a clear funding mdels, but at the time f writing the sustainability f the mdels remains uncertain. Avery (2017) in a recent editrial suggested that while sme general practices will be prepared t make a financial cntributin unless a mre generus apprach is ffered t general practices and the funding frmula is changed the scheme may lack sustainability. He emphasised that althugh pharmacists may smetimes ease GP wrklad the majrity f the impact f practice-based pharmacists will be n quality and safety. Freeman et al, (2016) in their reprt f their Australian study have suggested a mre flexible mdel, which in thery wuld allw custmizatin f specific GP practices t match their wn needs. Uptake by patient s pses as a cmmn barrier in many studies reviewed (Green et al., 2016, Sake et al., 2016), patients d nt realise that the service is available and what kind f care might be expected. The perceptins f ther health care prfessinals can als be a barrier, particularly that f GPs (Tan et al., 2014a, Wilcck and Hughes, 2015, Adepu and Nagavi, 2006, Freeman et al., 2012b, Saw et al., 2017). Lack f infrastructure is als a cmmn barrier (Freeman et al., 2012b), many general practices d nt have a spare rm t accmmdate a pharmacist. Freeman et al. (2012c) highlighted barriers t pharmacist integratin such as medical culture and remuneratin. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 16

18 What are the facilitatrs t ensure successful implementatin f this rle? Well established pharmacists are cnsidered t be mre suited t the rle. Che et al. (2005) highlight the imprtance f established relatinships with dctrs and patients stating that this wuld imprve trust and allw fr mre inter-prfessinal wrking. Pharmacists have mre time t evaluate medicine usage and reduce medicine wastage (Khachi, 2014) and s clearly there is a cst saving benefit related t the medicines budget. Accrding t ne study, independent prescribing pharmacists wuld benefit the GP practice mre as the pharmacist can drastically reduce wrklad f GPs as the pharmacist is mre capable in this aspect (Stne and Williams, 2015). If the implementatin f pharmacists in general practices has resulted in verall health imprvement this wuld naturally serve as a facilitatr (Khachi, 2014, Tan et al., 2013, Che et al., 2005, Zermansky et al., 2006, Zermansky et al., 2001, Sake et al., 2016). (ASU editrial) GPs benefit in multiple ways frm the pharmacist presence. Pharmacists supprt and input are prvided in a timely manner in instances when they may nt have previusly been sught, frm clinical meetings t incidental ( crridr ) cnsultatins. The practice pharmacist and GP relatinship allws fr advice tailred t the GP s preferred style and immediate needs and enables nging, lng-term cllabratin n mre challenging cases. Further, GPs are mre likely t enact advice frm a trusted and respected clleague than recmmendatins frm an external cntractr. Freeman et al. (2012c) highlighted facilitatrs t pharmacist integratin such as remuneratin and training, benefits f integratin such as access t the patient s medical ntes, and ptential funding mdels. Blndal et al. (2017b) cncluded that direct cntact between the pharmacist and GPs is better when wrking in the same building and that pharmacist s access t medical recrds is necessary fr ptimal service. Pharmacists having ther rles wrking in the practice (such as educating ther health care prviders), and the pharmaceutical care service needing t be well structured and streamlined t have benefits. Hwever, the ne thing the GPs interviewed in this Icelandic study mentined mst was the imprtance f the face-t-face cmmunicatin. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 17

19 Findings respnses t the research questins Intrductin The appendices prvide an verview f the key findings presented in respnse t the riginal research questins f the evaluatin and full underpinning data. A cmprehensive verview f supprting evidence in empirical data is held in Appendices B-F. The rle and activities undertaken A wide range f activities undertaken by CPs were reprted and bserved. These are difficult t hmgenise as crss-site practice is largely variable and lcalised. Many CP tasks were fcused n utcmes related t medicines ptimisatin. Senir CPs time was split between clinical and leadership tasks with sme f their time spent in patient facing wrk and the rest dedicated t scheme management and mentring f less experienced pharmacists. A small prprtin f CPs (2%) reprted nly cnducting nn-patient facing rles, largely in audit psitins similar t the established CCG pharmacist rle. These have impact n medicines ptimisatin by linking the natinal agenda arund medicines ptimisatin with lcal needs and practices. Mst CPs (98%) undertk patient facing wrk, fcusing n cmplex medicatin reviews, in particular with patients with lng term cnditins (cmmnly diabetes, hypertensin, asthma, COPD, mental health reviews and recnciliatin fllwing discharge frm hspital) and plypharmacy. 38% reprted undertake medicatin reviews in persn every day and 30% several times per week. Fr 70% they classified this as a majr part f their rle. There was evidence in many cases f this medicatin review invlved deprescribing. Betty believes there is an ptimisatin and r safety interventin in 70% f her cases. In a medicatin review, chrnic disease review, I wuld say mst patients we see we make sme srt f interventin. Be it very small t stp the meds, changing meds. CP Betty A large prprtin f CPs were respnsible fr streamlining the discharge recnciliatins prcess fr patients; 63% ding discharge review every day and 21% several times per week. This was acknwledged by a wide range f participants as having a significant psitive impact n patients and lcalised practice which ptentially led t reducing hspital readmissins. Several CPs were fcused n wrking with patients with mental health needs with a specific agenda t reduce piate prescribing. Several patients reprted successful reductin in piate use with supprt frm the CP. The external stakehlder SWOT analysis data shwed that external stakehlders perceived active deprescribing t be ne f the key strengths f the scheme relating t impact n patients. There were several examples given in interview by practising pharmacists where patients appreciated having their number f tablets reduced. Several site leads reprted that CPs were nted fr their high quality wrk especially with respect t LTCs including significant wrk n deprescribing. There was a strng feeling frm sme participants that with regard t medicines ptimisatin, it wuld be impssible t measure this, as primary care is very multidisciplinary and therefre inseparable frm the wrk f ther healthcare prfessinals in primary care such as GPs, nurses and CCG Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 18

20 pharmacists. Sme site leads hwever suggested that deprescribing is measurable and culd be a KPI, sme CPs resist this as a KPI measurement as deprescribing may nt always in the patients best interests. Several sites reprted lcally fcusing wrk n deprescribing in key areas such as elderly, specific cnditins r mental health. Sme sites have tracked deprescribing where linked t a specific area f wrk fr example ne case study site prvided evidence f a CP-led review f prcesses and better use f a prescriptin clerk leading t a 25% reductin in medicines management csts in 3 mnths. A large prprtin f CPs reprt giving lifestyle advice and this is reinfrced by patients wh agree that their appintment with a CP helps them t understand and adjust their healthy lifestyle behaviurs. This advice can als supprt medicines ptimisatin. In ne case study example a CP helped Patient L t imprve his self-care thrugh an imprved diet, smking cessatin and gradual supprted reductin in his piate use which cntributed t significant imprvements in his diabetes. The wrk f CPs is largely fcused n their specialisms in medicatin and fcusing n planned and lng-term care ver acute care. Hwever, there is sme evidence f rle stratificatin int acute care accrding t lcalised demand. Our study was nt set up t evaluate quantitative changes in patients health utcmes, hwever, frm the data we have btained there is evidence f a wide range f wrking practices which culd impact n patient utcmes including the fllwing: Imprved (right persn right time) apprpriate care thrugh imprved wrkflw in general practice and specialized MDT Increased patient access t appintments access t bth planned and urgent care (higher prprtin planned than urgent) access t cmplimentary care such as vaccinatins and medicatin reviews patient satisfactin with their healthcare hlistic care f patients, leading t imprved utcmes patient understanding f their lng term cnditins and medicatins patient educatin n healthy lifestyles patient lifestyle changes benefitting verall health and cntributing t imprvements in lng term health cnditins increased adherence t medicatins, especially with LTCs (f particular nte were hypertensin, diabetes and mental health) care hme expertise and reductin in care hme referrals including primary care and hspital admissins management f link between prescribing and dispensing thrugh gd quality netwrks with cmmunity pharmacy patient safety thrugh errr minimizatin and increased mnitring medicines ptimizatin Reduced prescribing errrs Increased strategic prescribing achievement f QOF targets patient satisfactin with transitins between secndary and primary care Reduced piid use prescribing errrs patient readmissin pst discharge Imprved medicatin knwledge in wider clinical team leading t verall imprvements in care related t medicatins Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 19

21 It seems clear that stakehlders believe that the biggest cntributin CPs can make t primary care is in adding their expertise t the multi-disciplinary team by cntributing t issues arund managing medicatin, rather than being used as replacements fr ther clinicians. We aren't 'expensive nurses' r 'cheap dctrs' we bring a wide array f unique knwledge and skills and a fresh perspective, valued by patients and allied prfessins Cmment by CP in survey Practice staff perspective and sustainability Different clleagues in the pilt scheme perceive the rle and the benefits differently. The evaluatin explred the experience f the scheme frm the perspectives f a range f prfessinal grups. The fllwing describes these different perspectives. What is the general practitiner perspective n clinical pharmacists wrking in GP practices? GP cntributins t the scheme vary; there is ften a lead GP at the lead site wh psitively influences ther GPs and prvides verall clinical guidance t the scheme. GPs acting in the lead rle are innvatrs wh are already cnvinced f the psitive cntributin that CPs can make t primary care. There is evidence f mismatch in prfessinal expectatin as sme GPs expect CPs t arrive in a state ready t cnduct mre patient facing wrk than they actually are. GPs have t prvide significant early investment in the CP (in terms f clinical mentring) t realise later returns and the level f this cmmitment is nt always recgnised in advance. GPs are ften happy t prvide clinical lead fr a CP pst but rely n the supprt f practice site leads and SCPs t prvide management supprt GPs suggest that the CP rle is expensive t the practice and financial benefits are nt the main (r any real) mtivatin fr the rle develpment. GPs recgnise that CPs can cntribute t capacity but recgnise that the demands f general practice are such that these benefits are difficult t realise especially until the pst(s) becme well established and evidencing this is challenging. GPs see the rle as a unique and vital cntributin t the multidisciplinary skills mix. GPs recgnise the benefits f the CP rle primarily by their expertise than cntributin t utcmes. GPs wish t lcalize the CP rle accrding t the demands f the practice, and the specialisms f the CP. GPs believe that key perfrmance indicatrs fr the scheme shuld be evidence based and lcalised. GPs believe the rle t be sustainable; mst reprted that they will keep the ne they are wrking with after the funding expires. Many GPs expressed either thrugh data cllectin, r t the CPs directly, that they nticed significantly when the CP was absent (fr example fr hliday r training) and general practice wuld nw nt wish t wrk withut the cntributin f a clinical pharmacist. What is the site lead perspective n clinical pharmacists wrking in GP practices? Site Leads (SLs) are respnsible fr peratinalising the scheme lcally. SL psts are held by a wide range f prfessinal types, wrking fr a wide range f rganisatinal types including Private cmpanies, CCGs, Federatins and practices. SLs are usually knwn at CCG level fr previus experience wrking clsely aligned t the field. SLs benefit frm supprt frm CCGs, where it is ffered, but this supprt is variable by area and at different times thrugh the scheme. SLs previus Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 20

22 experience benefits the implementatin f the scheme. SLs take significant respnsibility fr management and implementatin f the scheme at a lcal level. SLs are the c-rdinating rle fr all thers in the scheme upwards t CCG level (and beynd) and acrss t GPs, SCPs, CPs and ther practice team. SLs are ften the team member wh manages cncerns and reslves issues lcally. SLs are ften the central c-rdinating pint fr administratin f the scheme including HR, indemnity, and finance. SLs are smetimes respnsible fr delivering inductin, training and mentring fr CPs, but mre ften supprt thers delivering these tasks. SLs express frustratins with the csts f external training t the practice that were unclear at the utset f the pilt. SLs are clearly fcused n the sustainability f the scheme; many have actins in place t sustain the rle beynd 36 mnths at the 24 mnths stage. SLs suggest that in rder fr their rle t be sustainable (at 36 mnths) CPs shuld be wrking fully autnmusly patient facing by 24 mnths. SLs recgnise that the CP rle will cause variance acrss the pilt sites and ptentially gaps in the wider pharmacy wrkfrce as CPs mve t this new rle. What is the MDT perspective n clinical pharmacists wrking in GP practices? Pharmacists reprted wrking clsely with ther clleagues in primary care in particular nurses, administratrs and ther pharmacists. There is sme evidence f initial cncerns and resistance in a small number f allied health prfessinals cncerned abut rle verlap. Hwever, n the whle the clinical pharmacists reprt psitive experiences f wrking clsely with a wide range f clleagues in the multi-disciplinary team (MDT). At mst sites lcalised inductins include shadwing f a wide range f clleagues, building relatinships, trust and understanding abut the rle bundaries. At sme sites mentring and training fr CPs is prvided by Senir Nursing staff and there are examples f tw way learning between nurses and Clinical Pharmacists. There is evidence f a small amunt f rle verlap (between nurses and CPs in particular in prvisin f care fr lng term cnditins) which practices find useful t supprt the wider staffing f the team and meet patient needs in the mst timely and efficient way. There is als evidence f CPs wrking clsely with healthcare staff in care hmes. Summary Data cllected frm CPs and their clleagues in general practice demnstrate their satisfactin with their CP clleagues and the benefits they bring t practice. Sme mismatches in expectatins have been identified. Several sites, and GPs are emphatic abut the benefits that CPs bring, hwever, this is mitigated by the likelihd f their status as innvatrs and early adpters. Overall the data cllected suggests that the majrity f sites, at a practice level, are seeking t emply their pharmacist when the pilt scheme funding ends. We see we can t survive withut pharmacists, they are part f what we d. GP Adam Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 21

23 Identify csts and effect f the Clinical Pharmacist rle This sectin cnsiders the return n investment (ROI) fr practices cmmitting t the pilt scheme. In identifying the csts and effects f the psts, stakehlders can make infrmed judgment abut the level f ROI. Cst The cst f the CP t the practice is 40% f salary in year 1, 60% in year 2 and 80% in year 3. (NHS England 2015) Salary fr the CPs in General Practice is nt specified as independent businesses general practices d nt need t take accunt f agenda fr change, hwever it is bradly recmmended that psts fr CPs are level 7 ( 31-41k) and Senir CPs are level 8a ( 40-48k). (NHS Emplyers 2017) Additinal csts t the practice include the backfill time f the GP (r ther experienced healthcare prfessinal) t prvide direct mentring. While a cntract exists t reimburse GPs fr registrar training, there is n similar prvisin in relatin t the CP pst and this must therefre be brne as a cst t the practice (since this time culd alternatively be spent in cst-generating activity). As any effect f the rle invlves the time f the CP in practice, any reductin in this time is, in effect, a cst f the scheme. The ttal number f wrking days in ne year averages 260, reduced by annual leave t 233. The amunt f time spent by CPs at ff-site training events is year 1 is identified by several sites as a minimum f 18 days fr CPPE training (plus additinal time fr prescriber training (if nt already qualified) therefre reducing wrking capacity f the full-time CP further by a minimum 7.7%. Hwever, the time spent in training is nt prprtinal t the jb which may be held n a part time basis. Several small sites reprted having a pharmacist wrking fr nly ne day per week. In this case the cst f the verall wrking days and annual leave is pr-rata t the pst but the cst f the training remains cnstant at 18 days which may rise further t accunt fr up t 38% r mre f the time spent by a CP in practice. Further the integratin and inductin in the pilt site is significantly hindered and there is evidence this has significant negative impact n the establishment f the rle. This time reduces significantly after year ne, but this pints t a heavy cst t the practice in the first year, ptentially disprprtinally disadvantaging smaller practice sites. Finally, there may be a cst t sites f managing the scheme lcally (which may fall t a range f prfessinals) and may include time spent peratinalising the rle, leading n the rle develpment and building netwrks, and cnducting lcal research and reprting natinal KPIs. Effect The effects f the rle are materialised thrugh a wide range f benefits. The CPs in rle have cnducted a large amunt f medicatin reviews, data frm the rutinely cllected service data suggests that medicatin reviews are the sle task f the pharmacist. Since each f these medicatin reviews wuld have been a cnsultatin cnducted by an alternative healthcare prfessinal this represents an increase in capacity, largely fr GPs and t a lesser extent nurses. Several case study sites reprted specifically increasing GP capacity (Site A tw appintments per GP sessin, Site B ne hur f GP time per day) as a result f the CP rle. At many sites the release in capacity is realised thrugh new divisins f wrk. CPs taking n medicatin related wrk releases GPs t fcus n areas mre apprpriate t their expertise. At mst sites there is evidence f basic prescriptin apprval tasks (e.g. repeat prescriptin authrisatin) and Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 22

24 queries that wuld take up t an hur f GP time each day being released (frm their nline tasks lists) by CPs in their nn-appintment times. Release f capacity increases patients access t appintments. Several patients suggested that they enjyed the (cmparative) ease f access t an appintment with CP at a time where it is appreciated that access t General Practice can be limited. Furthermre, patients appreciated releasing GP appintments which might have been related t basic care f their lng-term cnditins t increase access fr thers t acute appintments. Data shws that CPs ffered variable appintment lengths t patients accrding t their time in pst and t patient needs. Patient data shwed that they appreciated these lnger appintments that ffered the pprtunity fr an in-depth high quality review. Several patients reprted t the evaluatin that as a result f lnger appintment times they felt they had a better understanding f their medicines and health. Several examples were given (by all stakehlders) f increased medicines ptimisatin during the medicatin review imprving adherence, deprescribing, and errr reductins. At many sites there is evidence f CPs specialising n the care f lng-term cnditins. At Site B there is a new divisin f wrk between an acute care team led by the GPs and a planned care team managed by senir Nursing staff and including the CPs, and ther allied health staff. Practice stakehlders give several examples f where CPs imprve the repeat prescribing prcess and quality. Data frm site E shws a lcalised measure f the number f interventins made t synchrnise patients repeat medicatin (imprving patients care path) 48 by the GP by cmparisn with 361 by the CP. Several sites reprt increases in safety and reductin in errrs as key benefit f the CP rle. Patients wh cntributed t the evaluatin spke highly f the benefits f their appintments with CPs. All patients appreciated the lnger appintment time the CP culd ffer and suggested that they benefitted frm the pprtunity t discuss multiple cnditins r issues within ne single appintment. CPs and patients reprted that ffering lifestyle advice was an imprtant part f the appintment. Survey data shws that ver 50% f CPs give lifestyle advice every day and 65% see this as a majr part f their rle. Several patients reprted that during an appintment with a CP they discussed their healthy lifestyle chices and ften made chices t imprve their chices thrugh simple changes suggested and encuraged by CPs. CPs suggested they used mtivatinal interviewing techniques t encurage healthy lifestyle changes. Sme patients reprted an imprvement in their verall health and lng term cnditins as a result f nging advice and supprt f a CP. These benefits are highly difficult t quantify. The types f appintments a CP can undertake develp ver time, accrding t a wide range f variables including their cnfidence, experience, mentring and prescribing status. Site leads suggest that CPs need t wrk autnmusly by the end f the secnd year t be sustainable. While sme f the abve effects are quantifiable such as numbers f appintments undertaken by CPs, each f these has limitatins (fr example it cannt be assumed that each CP appintment is in fact is a direct release fr a GP appintment, and in fact n ccasin additinal appintments are generated where referrals are made). Sme f the benefits are far mre difficult t measure as they are cmplex and entwined with a wide range f cntextual factrs. Nnetheless examples f all the benefits identified in this sectin were cllected as evidence fr this reprt and can be utilised as an utline f the rle effect. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 23

25 Return n investment The csts identified are mst significant in year 1, reducing in year 2 and again int year 3. This tapering matches the mdel f tapered funding t a certain extent. It culd therefre be assumed that the funding is prprtinal t the cst r time investment required in the early stages f implementatin, dependent n actual csts t sites in the first year. Equally the effects f the rle develp ver time being limited in year 1, especially fr thse withut independent prescribing cmpetency, but increase ver the secnd year t a pint f autnmus wrk and self-sustainability in year 3. Several sites reprt understanding f the tapered mdel and investment and time required t realise the return n investment. Sme GPs shwed a lack f full understanding f the csts f the scheme, r have unrealistic expectatins abut the time t realise the benefits f the scheme, and expect a faster return n investment than is pssible. Sites expect that in return fr time spent cllecting and returning KPIs fr natinal evaluatin they will be infrmed abut hw they cmpare t the natinal scheme in a timely manner. Sites wh cnduct lcalised research n their wn key perfrmance targets can prduce lcal valuatins n their return n investments. A range f lcalised measurements is reviewed in respnse t the next key evaluatin research questin. Effects f the pharmacist rle are materialised thrugh a wide range f benefits utlined abve. A key number f these benefits are difficult t measure quantitatively in a rigrus manner and subsequently evaluate ecnmically as the cmparatr will vary widely. T achieve this with any degree f certainty requires a clearly defined set f parameters such as prescribing and hspital admissins withut any ptential cnfunders. One way t achieve this is t define key criteria and measure these ver time fllwing the interventin f deplying a pharmacist in the practice, perhaps using practice level data if individual patient level data is unavailable. This reprt utilises evidence f benefits realised experientially by stakehlders captured thrugh qualitative investigatin and while it is acknwledged there is legitimate appetite fr the return n investment t be quantified, this can be cmplex where benefits are related t the qualitative. Nt innvative, just cmmn sense that she shuld have been in rle fr years/decades. Excellent value fr mney and imprves patient medicatin care GP Survey data, pen cmments Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 24

26 Develping and capturing cst and effect Measuring the return n investment fr Federatin sites requires a measure f bth incme and expenditure as well as effectiveness in the frm f quality indicatrs. With respect t measuring csts each site keeps recrds f CP actual days wrked and in training, salaries paid t CPs and additinal csts such as training expenses. Sme sites track time spent mentring prvided by SCPs r GPs, but thers d nt, due t the significant additinal burden and lack f timely feedback. There will always be intangible csts caught up the scheme related t develpment and netwrking that will be impssible t recrd. Measuring effects is mre difficult as practice is s variable and lcalised that centralised natinal KPIs will always disadvantage sites wrking t alternative lcal pririties. Sme key measurements such as numbers f appintments undertaken and medicines ptimisatin measures such as safety and deprescribing are the easiest t capture. Hwever, there is sme cncern that these measures d nt nearly give a clear measure f the actual benefits f the rle. Benefits which are far harder t measure are thse such as impact n verall lng term cnditins, impact n lifestyle changes, impact n hspital readmissins and efficiencies gained thrugh the scial re-rganisatin f care delivery thrugh the new rle. While it is acknwledged that CPs can have a significant psitive impact n these areas, ther intertwined cntextual factrs render these measures invalid against a single rle within the scpe f this study. Further specific ecnmic r health evaluatins may take suitable methdlgical appraches apprpriate t research this area specifically fr establishing measurements f the impact f the CP rle n these factrs. Furthermre, there are a wide range f benefits that are pssible t capture and reprt but difficult t measure accurately frm and ecnmic perspective fr example scially fcussed benefits such as increasing MDT knwledge, time saved in rutine queries and administratin, time saved in wrking with thers in cmmunity and hspital envirnments and changing the efficiency f lcal wrkflw. These benefits demand nging qualitative evaluatins and reprting fr sharing psitive effects. Lcalised data cllectin is practiced acrss a wide range f innvative pilt types. A key example f this is shwn in appendix A. Utilising lcally defined measures and a key member f staff t cnslidate data allws sites t cnduct valuable lcalised effect measurement t facilitate their lcal return n investment calculatins. Clearly identified rles and targets at an early stage f the scheme are useful t facilitate later data cllectin measures. A natinal rle cllating and facilitating the sharing f this lcal innvatin and expertise wuld be beneficial. Sme f this wrk has already been cnducted by ther external stakehlders. (Primary Care Cmmissining, 2017) Currently lcalised data cllectin is ften crdinated and cnducted by SLs n behalf f multiple practices and as well as natinal key perfrmance indicatrs they can reprt n lcal pririties. Sme CPs have respnsibility fr lcal data cllectin and there is evidence f a grwing understanding amngst CPs abut the need t take respnsibility fr evidencing the benefits f their rle. Furthermre, practice sites (at a level lwer than Federatin sites) appreciate data returned against the individual and the practice, as well as brader level data t help drive cntinuus quality imprvement. At sme sites CPs track the effect f their rle t discuss as part f their nging mentring and individual appraisal. A generic mdel f measuring cst and effect wuld therefre measure bth csts and effects at a brad natinal level (including brad ecnmic evaluatins f numbers f appintments, interventins and safety) but als against specific lcally derived targets. Staff activity shuld be tracked, bth f the CPs and senir CPs but als against the wrk f ther prfessinals where pssible. Mdels f gd practice in lcalised target setting and measurement and evaluatin shuld be centrally supprted, reprted and shared. Evaluatins shuld take place ver the full 3 years f ne full Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 25

27 scheme t evidence the implied later reducing csts and gains in effect. Evidence frm evaluatins shuld meaningfully infrm the develpment f the scheme n a frmative and summative basis. Facilitatrs and barriers What are the barriers preventing successful implementatin f this rle? Supprt fr pilt sites frm NHS England centrally is limited (lw numbers f centralised supprt staff) and at lcal area team level it is variable and unsupprted (i.e. n funding fr staff t supprt the scheme). Sites with limited previus experience have n base t build upn. Current participants are significantly experienced and likely t be innvatrs but this is likely t reduce ver wider rllut f the scheme. Whilst this is nt a barrier t the current scheme, it implies a ptential barrier fr future implementatin as the pl f available pharmacists reduces and thse recruited frm mainstream rather than innvatin psitins. Apparent lack f natinal, widely publicised cmpetence assessment and capability framewrks fr the CP rles leads t wide variance in ability, wrking practices and utcmes. This is mitigated t sme extent by the training prvided t CPs which acts as a facilitatr t the scheme. Indemnity can be prblematic, time cnsuming and expensive fr thse with n previus experience f negtiating indemnity fr pharmacists. The significant majrity f sites in the pilt wave have selected a rati f pharmacists t list size f 1:15000 r less. Patient list size will limit the embeddedness f rle and quality f service and limit applicatin types. The rati disadvantages smaller sites whse pharmacist s time will be prprtinally less n site than at larger sites. Sites with pharmacists wrking less than full time take lnger t realise benefits than thse wrking full-time, meaning that it is likely t take lnger t realise the benefits in smaller GP practices. There is evidence that the rle shuld be a minimum f tw days per week at each site in rder fr the CP t be embedded in lcal practices and prvide cnsistent patient service. There is wide variance in the mentring experienced by CPs. Rati f higher than 1:4 SCP:CP will limit the quantity and quality f mentring that can be prvided by SCPs. There is evidence f great variance in lcalized training and inductin and n financial supprt fr lcalised training. Currently training fr CPs is externally cmmissined by HEE n behalf f NHS England in a centralised mdel. The training has high pprtunity cst as it is time intensive; this has benefits fr CPs but ften significant cst t practices. Training which is standardized and nt persnalized t different levels f CPs ability and experience can be ineffective. Within the peratinalizatin f the pilt sme early training was ffered at very shrt ntice, r t late in the scheme t be useful. There is a lack f independent prescriber pharmacists and therefre the CP rle requires the time and investment t include prescriber training a further time and cst implicatin t practice thrugh backfill GP prvisin fr mentring time. There is a lack f direct cntact with sites, especially Site Leads, t influence externally cmmissined training as relevant t the develping rle. There is currently n assessment r cmpetency management assciated with training which many stakehlders deem as vital t the rle. Site lead rles are creatively funded, shrt term and lack sustainability but are vital t the success f the scheme. Senir CP rles may appear less sustainable due t their significant wrklad in supprting the scheme ver seeing patients. Other staff in primary care (especially nurses) may be initially resistant t the rle and fearful f verlap, but ften supprt the rle and its benefits and learn frm the expertise f the CP. There is evidence f a need fr, and develpment f, a primary care MDT. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 26

28 There are quite ntable levels f turnver with 15 sites reprting turnver f 1 CP pst and mre than 1 CP pst in13 sites. Five sites reprted turnver f 1 GP practice and 10 sites reprting turnver f mre than 1 GP practice. In case study sites turnver averages at 1:7 fr pharmacists and 1:8 fr sites (Appendix E). There is ften a mismatch in GPs expectatin f the CP and the scheme and therefre GPs make (smetimes unrealistic) assumptins abut CP capability. GPs need guidance t be invlved in CP recruitment. GPs wh are nt site leads and d nt mentr CPs take lnger t understand the rle and its benefits. GPs have t invest significant time in mentring but are unlikely t realise the benefits until after the first year f the scheme nce the CP is established in the pst. Terminlgy arund the rle f CP is unclear, especially fr patients. Patients d nt clearly understand the difference between a cmmunity pharmacist and ne wrking in general practice. The CP term is cntrversial and nt widely accepted. There is a clearly defined senir rle but a reluctance t als have a junir rle and a clear rute f prgressin fr the rle. The current fcus f key perfrmance indicatrs and evaluatin is clinical skills and cst and value, nt quality and medicines management. Centralised key perfrmance indicatrs were nt centrally cllated and analyzed and there is n nging centralised analysis f the scheme utputs. This has disengaged sme sites frm cllecting and returning data. There is significant limitatin t the value f the current rutine service data. There is limited supprt fr lcalised evaluatin and reprting and n crdinated analysis f lcalised scheme utputs. Lcalised practice accrding t demand means that sme sites will meet key perfrmance indicatrs because they are strategically nearer t the lcalised demand, nt because they are necessarily perating mre effectively. Evaluatin shuld infrm future practice but later phases have been rlled ut befre this evaluatin is cmplete. Externally cmmissined training is nt being independently evaluated. What are the facilitatrs t ensure successful implementatin f the CP rle? Strng clinical and business management at a lcal level is vital t the success f schemes. One site acts as a lead fr thers, ften pilting new areas f wrk and develpment fr CPs. The Site Lead rle and the way it is implemented is very wide ranging but vital t the success f the peratinalizatin f the scheme, especially frm the bid stage t the end f the first year f the scheme. Sites reprt that a centralised apprach t HR and business management can benefit peratinalisatin, especially in the first year. Clse links between the site lead and the lcal area team at CCG level can als facilitate the implementatin f the scheme. At the early implementatin stage a clear jb descriptin and bundaries fr the rle can facilitate implementatin. Successful recruitment (chsing the right persn fr the rle) is crucial t the success f the scheme and sites reprt that cmbined clinical and management recruitment appraches are beneficial. A clear jb descriptin and bundaries can facilitate early discussins rund indemnity. Sites reprt that they benefit frm the ability t lcalise wrk activities depending n the needs f the practice and the abilities and interests f the CP. Gd quality CP site level integratin is vital t the success f the rle. This can be achieved thrugh: Maximising time spent n site as pssible (at least tw days per week per site) Shadwing key staff Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 27

29 Time spent telephne triaging / n receptin Lcalized training including intrductin t primary care bradly and lcally Gd quality CP site level mentring is vital t the success f the rle Mentring can be ffered by GPs r Senir CPs r Site Leads, r cmbinatins Best practice mentring is ffered by multiple staff Reduced scafflding apprach t mentring, utilised fr GP registrar training, is successful in building cnfidence Scaling tasks accrding t ability and cnfidence is imprtant Strng netwrking facilitates the develpment f the CP rle. The nging cmmitment t, and funding f, external training is a key facilitatr f the rle. Regular review and develpment f externally cmmissined training is beneficial. Maximizing the beneficial impact f externally cmmissined training and reducing the cst, time and stress implicatins fr practice and CPs wuld be beneficial. Cmmitment displayed by several participants t the develpment f a natinal advanced practitiner in primary care rle fr pharmacists facilitates the lng term develpment f the rle. Lcalised research f benefits facilitates the nging sustainability f the rle and the scheme. Sharing gd practice in lcalized research appraches facilitates learning acrss sites. Centralised tracking and mnitring f sites, including centralised research management and analysis facilities, facilitate nging research and evaluatin. Frmative and summative evaluatin can facilitate and infrm the iterative develpment f later waves f the scheme. Gd cmmunicatin by NHS England t bth CCG level and directly t sites can facilitate clear understanding f the rle. Onging cmmunicatin shuld cntinue with a wide range f stakehlders including cmmunity pharmacy, pharmacy prfessinal leadership bdies, patient grups, academics, and training prviders. Stakehlders reprt that they benefit frm sharing gd practice between sites, acrss sites, acrss areas, and natinally. Cllabrative wrking There are strng links with cmmunity pharmacy thrugh bth day t day wrk and thrugh netwrking pprtunities. In several sites the pharmacist had experience f cmmunity pharmacy prviding understanding f the challenges f crss-site wrking with General Practice. CPs reprt that the GP Pharmacist can prvide a gd and better link t General Practice fr cmmunity pharmacists. There is evidence that cmmunity pharmacy and CPs can wrk tgether and learn tgether and examples f gd practice and innvatin culd inspire develpments in their sites. At site A there are mnthly meetings between the CPs and lcal cmmunity pharmacies which has helped t imprve services and reslve lcal challenges mre expeditiusly. At site C cmmunity pharmacists are regularly invited t practice meetings by the CP. There are links with hspital pharmacy thrugh bth day t day wrk and sme netwrking pprtunities; n the whle these are less than links with cmmunity pharmacy. Discharge management is given as an example by several sites f needing t liaise clsely with bth hspital pharmacy and cmmunity pharmacy t ensure cntinuity f care fr patients. There was an example Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 28

30 f medicines ptimisatin and imprved patient care thrugh the pharmacist intervening in the practice administrative prcesses arund hspital discharge. Each case study sites gives examples f wrking clsely with their CCG, in particularly CCG pharmacists and medicines management teams, wrking clsely n natinal agendas. There is significant evidence f partnership wrking between CPs and care hmes in a range f innvative mdels. In site area H care hmes are aligned t a single practice and the practice MDT prvides direct supprt fr the lcal care hme and the CP is integral t this. Strengths and limitatins f the wrk The particular methd chsen fr this research (mixed methds with qualitative fcus) is aimed at painting a picture f practice and s enabled a rich descriptin f the barriers and facilitatrs perceived by CPs, GPs, patients and clleagues wh have experienced implementatin f CPs in England. The participatin f a range r different participants including patients prvided pprtunity t gain a deep insight int each f the case study sites. Detailed quantitative data acquisitin was limited due t time and resurce available. The survey was made available widely t pharmacist participants prducing gd descriptive measures f activity, hwever this culd be subject t self-reprting and participatin biases. It was nt pssible t capture detailed independent measurements f activities, patient utcmes and assciated csts. The data cllected hwever prvides useful insights int hw further statistical and ecnmic data might be cllected. The sample fr survey data is largely pprtunistic and in the absence f verall chrt data makes n claim abut generalisability. This evaluatin was restricted t a specific implementatin cntext (i.e., UK pilt scheme), t which its results are directly relevant, further generalisability f findings may be difficult, but transferability f findings t future iteratins f the scheme r ther schemes is may be pssible. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 29

31 Cnclusin Taking a mixed methds apprach allwed measurement f what was happening in the scheme underpinned by understanding hw the scheme was experienced by key stakehlders. CPs have made a unique and valuable cntributin t the primary care skill mix. Pharmacists cntribute significantly t patient safety, bring medicines and prescribing expertise, supprt with prescribing tasks, supprt fr patients with lng term cnditins including supprt fr healthy lifestyles. They have imprved medicatin knwledge in the wider clinical team leading t the prspect f verall imprvements in care related t medicines. The intrductin f pharmacists has led t increased capacity in practices. Althugh the rle requires financial cmmitment frm practices, GPs believe the rle t be sustainable, mst will keep the ne they are wrking with after the funding expires. Csts and effects f the rle were utlined. There remains sme mismatch between GPs expectatins f ROI and bth the depth f cst and length f time fr returns t be realised. CPs integratin and availability in practice is imprtant fr cntinuity f care. In rder t be successful and feel part f the team, pharmacists need t be visible, cmmunicate well and be flexible and innvative. CPs need t spend mre than ne day per week in pst t feel a sense f belnging, and the mre time spent in rle the faster the level f integratin. CPs need training and time fr learning n-the jb t understand the way that primary care wrks. Training and mentring is vital t the develpment f the scheme but at a cst t practices. Csts are highest in the first year f the scheme and time is needed t realise the benefits f the rle. Senir clinical pharmacist rles vary and need t be further defined and evaluated fr sustainability. Site leads are clearly fcused n the sustainability f the scheme, many have actins in place t sustain the rle beynd 36 mnths at the 24 mnths stage and in rder fr their rle t be sustainable (at 36 mnths) CPs shuld be wrking autnmusly patient facing by 24 mnths. The clinical pharmacist in general practice rle is already causing variance and ptentially gaps in the wider pharmacy wrkfrce. Wrkfrce planners need t take this int cnsideratin. Key perfrmance indicatrs fr the scheme shuld be evidence-based and lcalised. There has been limited value t the mnthly return data cllected s far, and n feedback, creating resistance frm sites. Future natinal reprting shuld be limited t key infrmatin nly and lcalized reprting shuld be encuraged and facilitated. Evaluatin shuld actively infrm future iteratins f scheme develpments. If integratin f pharmacists int general practice is t be successful there is a need t be flexible t develp their rles based n individual general practice needs whilst perfrming within a recgnized cmpetency framewrk. Fr cntinuing success there will be challenges t vercme, such as defining standards fr these new rles, and acceptance f patient-facing pharmacists by existing GP team members and by patients. It is likely that the prfessinal identity f pharmacists may change and general practice teams will need t find a new equilibrium. If these transitins can be facilitated, then CPs can increasingly prvide a bridge between the patient and their medicines. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 30

32 Summary f recmmendatins As a result f the wrk carried ut in this evaluatin the prject make the fllwing recmmendatins: NHS England shuld direct and enhance effective tw way cmmunicatin Maintain clear lines f tw way cmmunicatin between NHS England t Clinical Cmmissining Grup level and site level Maintain nging cmmunicatin abut the scheme with a wide range f stakehlders Maintain nging data cllectin with sites and ensure regular reprting and feedback Further research t include Lcal Areas Teams and practice site leads as a significant stakehlder set Organise and develp pprtunities t share gd practice NHS England shuld further manage expectatins f all stakehlders thrugh clear guidelines and cmmunicatin Manage GP expectatins f the clinical pharmacist rle capabilities and time fr return n investment Manage practice site leads expectatins f cst and training cmmitments Manage lcal level expectatins f wrap arund respnsibilities fr the clinical pharmacist rle (i.e. clear guidance n senir clinical pharmacist mentring, GP mentring, Practice site lead and Lcal Areas team supprt) NHS England shuld facilitate internal cmmunicatins Supprt gd quality lcal level cmmunicatin t aid integratin Supprt lcal netwrks with external parties such as hspital and cmmunity pharmacy, CCG and wider allied health services Share examples f gd practice Natinal, widely publicised cmpetencies fr the clinical pharmacist rle shuld be develped t aid rle develpment and prgressin and t facilitate interprfessinal trust. Cmpetencies shuld be based n current and future natinal needs analysis thrugh nging cnversatin and liaisn with key stakehlders. The steering grup t develp natinal cmpetencies fr the clinical pharmacist rle shuld include thse wrking in primary care (Pharmacists, GPs, site leads and ther allied health staff) as well as representative bdies (RPS and RCGP) and thse respnsible fr regulating (GPhC) and funding natinal pharmacy educatin (Office fr Students infrmed by NHS England). Lng term wrkfrce develpment and training plans shuld take cnsideratin f the clinical pharmacist rle as the third majr career chice fr pharmacists alngside hspital and cmmunity practice including due cnsideratin f remuneratin Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 31

33 Impact f the CP rle n the changing pharmacist wrkfrce and hence undergraduate educatin is an imprtant lng-term cnsideratin and area fr further research We als recmmend that future evaluatin wrk takes accunt f the fllwing: Measurement f the impact n General Practice Capacity and wrklad Requires detailed data abut the functin f the CP rle. Sme f this can be easily cllated at site level and returned fr wider evaluatin Requires cmparative data abut the functins and impact n ther rles Medicines ptimisatin Data abut specific medicines ptimisatin initiatives, their desired utcmes, effectiveness and cst effectiveness Safety Further evaluatin may cnsider the impact f the CP rle as an interventin t imprve safer practice Sme actins reprted and bserved make significant impact n the discharge prcess. CP interventins are likely t have prevented emergency hspital readmissins, but this may be difficult t evidence. Further evidence may require detailed patient data t be cllected and interactins analysed fr ptential lng term effectiveness and cst effectiveness. Case study data highlights that CPs have significant impact n prescribing psychtics and care hme safety. These culd prve useful pprtunity fr further evaluatins. In additin t measurement f key perfrmance metrics, qualitative data must be cllected t underpin the understanding and interpretatin f quantitative findings Measurements f impact n pharmacists Jb satisfactin, autnmy and wrking relatinships Annual survey Increase in clinical skills and evidence f learning Cllected by natinal training cmmissiner Measurements f impact n patients Patient surveys / fcus grups Measurements f health utcmes in patients with particular lng-term cnditins Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 32

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36 Pttie K, Farrell B, Kennie N Sellrs C, Martin C, Dlvich L (2009) Pharmacist s identity develpment within multidisciplinary primary health care teams in Ontari; qualitative results frm the IMPACT prject Research in Scial and Administrative Pharmacy 5, Primary Care Cmmissining (2017) Clinical PHARMACISTS in General Practice Accessed 31/1/18 Sake, FTN, Wng, K, Bartlett, D J, Saini, B. (2018) Integrated primary care insmnia management in Australia. Research in Scial and Administrative Pharmacy 14, Saw, PS, Nissen, L, Freeman, C, Wng, PS & Mak, V. (2017) Explring the rle f pharmacists in private primary healthcare clinics in Malaysia: The views f general practitiners. Jurnal f Pharmacy Practice and Research, 47, Sharma, R. (2018) Pharmacists in General Practice Prgramme Update, presented at the Clinical Pharmacy Cngress 28 April 2018 Smith, J, Pictn, C. Dayan, M. (2013). Nw r Never: Shaping Pharmacy fr the Future. The Reprt f the Cmmissin n future mdels f care delivered thrugh pharmacy. Ryal Pharmaceutical Sciety, Lndn. Snell R, Langran T, Snyai P (2017) Patient views abut plypharmacy medicatin review clinics run by clinical pharmacists in GP practices. Internatinal Jurnal f Clinical Pharmacy 39(6): di: /s z. Epub 2017 Oct 11. Stne, MC, Williams, HC. (2015) Clinical pharmacists in general practice: Value fr patients and the practice f a new rle. British Jurnal f General Practice, 65, Tan, EC, Stewart, K, Ellitt, RA, Gerge, J. (2013) Pharmacist cnsultatins in general practice clinics: the Pharmacists in Practice Study (PIPS). Research in Scial and Administrative Pharmacy, 10, Tan, EC, Stewart, K, Ellitt, RA, Gerge, J. (2014a) Pharmacist services prvided in general practice clinics: A systematic review and meta-analysis. Research in Scial and Administrative Pharmacy 10, Tan, EC, Stewart, K, Ellitt, RA, Gerge, J. (2014b) Integratin f pharmacists int general practice clinics in Australia: the views f general practitiners and pharmacists. Internatinal Jurnal f Pharmacy Practice, 22, Tinelli, M, Ryan, M, Bnd, C. (2009) Patients' preferences fr an increased pharmacist rle in the management f drug therapy. Internatinal Jurnal f Pharmacy Practice, 17, Wilcck, M, Hughes, P. (2015) GPs' perceptins f pharmacists wrking in surgeries. Prescriber, 26, Zermansky, AG, Alldred, DP, Petty, DR, Raynr, DK, Freemantle, N, Eastaugh, J, Bwie, P. (2006) Clinical medicatin review by a pharmacist f elderly peple living in care hmes randmised cntrlled trial. Age and Ageing, 35, Zermansky, AG, Alldred, DP, Petty, DR, Raynr, DK, Freemantle, N, Vail, A, Lwe, CJ. (2001) Randmised cntrlled trial f clinical medicatin review by a pharmacist f elderly patients receiving repeat prescriptins in general practice. British Medical Jurnal, 323, Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 35

37 Appendix A Example f lcal data cllectin by a pilt site A number f sites have cllected lcal key perfrmance indicatr data. An example f the data cllected is prvided belw. Interventin Cmpleted by GP Cmpleted by clinical pharmacist Ttal dcumented medicine ptimisatin interventin in fiscal year N f Interventins t Synchrnise patients repeat medicatin N f interventins cnfirming patients drug mnitring is up t date N f interventins where medicatins stpped n medical advice N f interventins where medicines were practively recnciled N f care hme medicatin reviews undertaken in fiscal year N f interventins discussed with anther HCP N f interventins where medicines are discussed with cnsultant N f interventins fr advice t GP t change patient s medicatin N f interventins identifying bld tests were due N f interventins t alter a drug dsage schedule N f interventins t GP t advise STOP patient s medicatins N f interventins t GP t advise START f patient s medicatins N f interventins t ptimise drug dsage N f interventins where drug changed t identified interactins 2 97 N f interventins where drug directins nt adequate r apprpriate N f interventins where drug frmulatin inapprpriate 3 93 N f interventins where drug changed t mst cst-effective alternative N f interventins where drug treatment was n lnger needed N f interventins where medicines changed t generic N f interventins where medicines changed t branded N f interventins where patient supplied with medicatin advice N f interventins where new medicines were added N f interventins where recall has been arranged Care Management Plans practively reviewed in relatin t medicine management Discharge summaries reviewed in relatin t medicine changes fllwing inpatient stay reviewed Medicatin review cmpleted at Level Hspital admissins avided Medicatin review cmpleted at Level 2 withut patient Medicatin review cmpleted at Level 2 with patient Other Medicatin review cmplete Pst hspital discharge medicine related query with patient Antipsychtic review practively cmpleted 3 26 Telephne encunter regarding medicine related query Patient with dementia practive medicatin review Patient with learning disabilities - practive medicatin review 1 13 Regular repeat prescriptin review at pint f rdering r request Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 36

38 Appendix B Rutine service data Data cllectin Rutine service data was requested frm pilt sites in the frm f a mnthly Micrsft Excel spreadsheet return by . It was nted by the team that this created a significant administrative burden n the NHS England team managing the pilt, beynd that available, meaning that n central cllatin f data was pssible. The KPIs fr the pilt scheme included verall baseline data per site and mnthly returned data per pst. Baseline data fr each site included: Number f appintments Number f medicatin reviews per annum (GP/CP split) Number f patients supprted t develp care and supprt plan including self-management Ttal number f patients wh have attended 15 appintments r mre by age grup Ttal number f patients with dementia r learning difficulties Ttal number f patients with dementia r learning difficulties prescribed anti-psychtics Mnthly submissin data t be returned included: Number f psts at practice level (the level f return was nt clearly defied and as such is incnsistent) Amunt f time in pst / Sick Leave / Annual leave / hurs wrked (nt clear if this includes training) Number f appintment slts available/taken fr each member f staff Number f medicatin reviews Speciality area / type f wrk Examples f the submissin frms are shwn belw Sample practice baseline characteristic spreadsheet Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 37

39 Sample practice mnthly return spreadsheet Observatins f the evaluatin team with regard t rutine service data Data cllectin wuld need t be undertaken at multiple levels acrss the sites t prvide this data. The required data cllectin by CPs, SCPs and SLs carries a significant time burden mnthly. The data entry return requires sites t state the practice name and ODS cde rather than pilt site details. Whilst the return frm allws returns fr multiple pharmacists, it is likely this has caused cnfusin with reprting as many pilt sites have multiple pharmacists ver several sites, wh may have flexible wrking patterns acrss the sites practices. There is n mechanism t aggregate data crss-site centrally, and n resurce t d s. Sites are given basic guidance t cmplete returns but each site must peratinalise recrding therefre data is incnsistent and pr quality. During case study data cllectin it emerged that sites are nt acknwledged fr returning data r pursued fr nt returning data; data is therefre spradic and incnsistent. As a result the rutine service is f limited value. Summary f rutine service data prvided t evaluatin team NHS England prvided data t the evaluatin team n 9 practices (nt federatins) representing a very small amunt f thse in the pilt. It is nt clear upn what criteria NHS England chse t share data frm these sites. The tables that fllw prvide a summary f the data submitted by the 9 sites. The sample data at the practice level (Table B-1) reprts that the practices have a wide list size ( ) and wide variatin in the average available numbers f appints per mnth ( ). This ten-fld variatin in appintment availability is nt prprtinal t the variatin in list size. The data captured suggests that a significant number f medicines reviews are being cnducted by GPs which is cunter t the expectatin that Pharmacists will cnduct many f them. It is clear frm the submissins that many pharmacists are new in pst; many may have been ff-site fr training and ther related activities. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 38

40 Individual pharmacist data (Table B-2) wuld suggest that mst pharmacists are ding medicatin reviews (range 0-242%) hwever this is nt directly linked t prescriber status. The reprted figures wuld suggest that there are cmpletin errrs in the rutine service data. It was nt within the pwer r resurce f the evaluatin team t verify data supplied. Pharmacists reprt a range f specialisms sme are disease fcused whilst thers are task riented. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 39

41 Practice characteristics Practice A B C D* D* E F G H I J K L List Size (nearest 1000) Clinical system EMIS EMIS EMIS EMIS EMIS EMIS EMIS EMIS EMIS EMIS EMIS EMIS EMIS Other nn-pilt pharmacist Ttal number f patient appts 1 (all staff 2 ) available 15/ Average number f patient appts available per mnth 15/ Medicines reviews Ttal number f med reviews undertaken between 15/16 Ttal number f med reviews undertaken by a GP between 15/16 Percentage f the ttal number f med reviews undertaken by a GP Ttal number f patients supprted t develp care and supprt plans, inc. self-management plans 15/16 Patients wh have attended 15 appts with a GP in age grup % 78.4% 82.8% 87.9% 87.9% 39.4% 82.8% 87.3% 69.5% 73.3% 99.3% 69.6% 51.1% [0-9] years ld [10-19] years ld [20-39] years ld [40-59] years ld [60-69] years ld [70-89] years ld [90+] years ld Patients registered t practice with a diagnsis f dementia r learning disabilities Ttal number in 15/ Ttal number in 15/16 prescribed anti-psychtic meds Percentage f the ttal prescribed anti-psychtic meds 8% 25% 8% 16% 16% 111% 8% 36% 4% 25% 25% 17% 0% Table B-1. Summary f General Practice rutine service data frm 9 practices (A-L) 1 Face t face and telephne appts; 2 All staff includes with GP, Practice Nurse, Clinical Pharmacist, Health Care Assistant and/r Advanced Nurse Practitiner; 3 Ttal number f patients wh have attended 15 appts with a general practitiner in the perid t in age grup [stated] as at ; *Practice D has bth a CP and an SCP. Reprted practice data is aggregated acrss bth rles; 15/16 refers t the reprting year 1/4/15 t 31/3/16

42 Pharmacist Characteristics Practice A B C D* D* E F G H I J K L Pharmacist type SCP CP CP CP SCP CP CP CP CP CP CP CP CP Nn-Medical Prescriber Yes Yes Yes N Yes N Yes N Yes N N Yes N Whle Time Equivalent Activity: latest reprted mnth Number f appts 1 available this mnth by each CP / SCP Number f med reviews undertaken this mnth by each SCP/CP Ttal number f attended patient appts (all staff 1,2 ) Baseline - average number f patient appts per mnth in 15/16 Percentage f ttal number f patients seen by a clinical pharmacist this mnth Activity: Ttal within reprted perid % 4.6% 6.3% 1.9% * 1.9% * 2.0% 9.7% 9.0% 1.9% 2.9% 15.3% 4.1% 3.5% Number f appts 1 available this mnth by each CP / SCP Number f appts 1 attended this mnth by each CP / SCP Number f med reviews undertaken this mnth by each SCP/CP N. Mnths data derived frm Average Med Reviews % Med review 86% 31% 36% 0% 92% 54% 36% 24% 8% 242% 16% 29% 129% Specialisms reprted 3 Cardivascular disease Care plans Diabetes Discharge reviews General queries/medicines management Mental health reviews Minr illness Plypharmacy clinics Respiratry Smking cessatin Telephne cnsultatins Travel health Nthing stated Table B-2. Summary f Pharmacist rutine service data frm 9 practices (A-L) 1 Face t face and telephne appts; 2 All staff includes with GP, Practice Nurse, Clinical Pharmacist, Health Care Assistant and/r Advanced Nurse Practitiner; 3 Sites return specialisms as a free-text respnse. An absence f a tick des nt indicate that it is nt cnducted by a site; 15/16 refers t the reprting year 1/4/15 t 31/3/16

43 Summary Rutine service data cllected during the pilt scheme was pr quality and cannt be rigrusly analysed t prvide any useful measure f the scheme at part f this evaluatin. The evaluatin recmmends the appintment f an independent analyst t cllate all rutine service data cllected and returned by sites as part f the pilt scheme t date. Future data cllectin shuld be mdified t incrprate the fllwing recmmendatins Pilt scheme sites shuld jin with future wave sites t create cnsistent data returns Data shuld track the pint at which the CP returning the data is in the scheme t differentiate (year 1/2/3/pst) Sites shuld be allwed time, resurce and supprt t cnduct bth lcal and natinal data cllectin Centralised n-line data cllectin thrugh using standardised reprting templates, clcated within the clinical system Centralised dashbard f reprted data t allw sites and individuals t cmpare their perfrmance against thers Iterative develpment f KPIs accrding t lcal specialisms Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 42

44 Appendix C Natinal survey f pilt sites Audit data The three mnth audit mapped the current sites in the pilt scheme and established up t date cntact details fr all sites. Sites were mapped t cver a wide area f England. The map belw (Figure C-1) shws the lcatins f the pilt sites and prvides an indicatin f gegraphic spread. Figure C-1: Gemap f sites in pilt phase: Clinical Pharmacist in General Practice Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 43

45 NHS England were unable t prvide the evaluatin team with an up t date list f Clinical Pharmacists in pst as this infrmatin was nt rutinely captured by NHS England, the nly recrds being held at the level f the site that cmpleted the initial applicatin. The training prvider CPPE was als nt able t share an up t date list f Clinical Pharmacists as training was prvided n an Opt-in basis. The current NHS data suggests that the scheme currently perates as fllws (frm the riginal applicatin data and CPPE training registers). 89 applicatin sites 451 Clinical Pharmacists WTE emplyed (491 psts) 658 GP practices acting as hsts t GP Pharmacists Therefre in rder t facilitate an nline survey and track respnse rates it became vital t cnduct an audit which culd clarify the numbers f sites and emplyees and establish a line f nline cmmunicatin in rder t facilitate an nline survey. An audit tk place ver June-September Each pilt applicatin site was cntacted by and asked t cnfirm their participatin in the pilt and prvide the names and addresses f the Clinical Pharmacists and the GP practices wrked at. A first request fr infrmatin was sent in June with fllw up s in July. In the event f nn-respnse a telephne call t the site was placed t establish this infrmatin. Supprtive s frm NHS England in August asking that sites participate in the evaluatin were helpful. Whilst the audit was being undertaken the research team cllabratively designed the cntent f the survey/s based n the riginal research questins submitted in the evaluatin tender. Whilst the riginal design had been t survey nly Clinical Pharmacists and their clleagues in the practice, an imprtant new categry f participants emerged frm cnducting the audit. The pilt site leads wh were cntacted fr the infrmatin abut Clinical Pharmacists were sharing valuable infrmatin abut the scheme and clearly played an imprtant rle in its implementatin. It was therefre decided t iteratively develp a survey fr this new categry f clleagues wh emerged as significant gatekeepers t the scheme, the clinical pharmacist and therefre the evaluatin research. Each iteratin f the questinnaire was pilted bth internally with the steering grup, and externally with a lcal sample f Pharmacists. Adjustments were made ver 5 runds f amendments t incrprate changes t design and cntent validity. The platfrm fr the nline survey was BOS, as this platfrm meets all data prtectin and lcal ethical requirements. Unfrtunately the ethical requirements t use this platfrm were prblematic since the platfrm was mved between prviders (University f Bristl t JISC) during the perid f the survey administratin withut prir knwledge t the team. This was raised as a cmplaint f service directly with the sftware supplier. This caused bth a delay t the survey and a disruptin during the survey perid that may have had a negative impact n respnse rates. The final versin questinnaire was distributed by n 27 th September, remained pen fr three weeks and clsed n 18 th Octber. Tw reminders were sent. Survey respnses were analysed descriptively using SPSS versin 24, with crss tabulatins where apprpriate Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 44

46 Survey findings Table C-1 Prvides a summary f the number f sites successfully audited and the respnses received t the survey Federatin sites Clinical Pharmacists NHS England riginal data (rigins unknwn) Audit data Survey respnses 52 (41*) 159 Survey respnse rate 68% (53%*) 42% Table C-1. Overview f audit data and survey respnses. *Bth site leads and clinical pharmacists were sent a unique survey cmpletin link. Several site leads shared their link s data presented includes ttal respnses and number f sites cvered marked * Clinical pharmacist participants The findings frm the survey give an verview f the early implementatin f the scheme including an verview f site cnfiguratins, perspectives n inductin, mentring and training, relatinships with ther key staff and wrk tasks and priritisatin. Demgraphics Demgraphic infrmatin abut participants suggests a diverse wrkfrce f Clinical Pharmacists wrking in GP practices. (Table C-2) There is wide variance in age, gender and ethnic backgrund f staff these psts. Apprximately 72% f psts are held my females, 63% are under the age f 40 and nly 53% are White British. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 45

47 Frequency (Percent) Gender Female 109 (71.2) Male 43 (28.1) Prefer nt t say 1 (0.7) Ttal 153 (100) Age grup (16.8) (22.6) (23.2) (11.6) (13.5) (7.7) (3.2) (0.6) (0.6) Ttal 155 (100) Ethnicity English / Welsh / Scttish / Nrthern Irish / British 81 (52.9) Any ther White backgrund 8 (5.2) White and Black African 3 (2) White and Asian 2 (1.3) Any ther Mixed / Multiple ethnic backgrund 2 (1.3) Indian 26 (17) Pakistani 10 (6.5) Bangladeshi 2 (1.3) Chinese 2 (1.3) Any ther Asian backgrund 3 (2) African 8 (5.2) Any ther Black / African / Caribbean backgrund 2 (1.3) Arab 1 (0.7) Any ther ethnic grup 3 (2) Ttal 153 (100) Table C-2. Demgraphic verview f CP respndents Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 46

48 Site cnfiguratin Data frm the survey demnstrates a rlling recruitment prgramme. 28% f CPs started their pst n the pilt scheme in April 2016 with apprx. anther 10% cming n bard each fllwing mnth until Octber when it slwed dwn t 5% per mnth then 2% thrugh t August 2017). 8% f respndents reprted that their psts replaced previus CPs, ptentially demnstrating a fairly high level f early rle turnver. [13 peple in the survey reprted that they had been emplyed t replace anther pst. This is 8.2% f the verall number f CP survey respndents (149) and therefre equates t 3.4% f the verall number f CPs in the audit data (379). This equates t 3% f the verall number f CPs frm NHS England data (451).] There is great variance in the cnfiguratin f psts. There are a lt f bth full time rles (37-42 hurs) and als part time rles with wide variance frm 8 hurs per week t Nearly half f all CPs (46%) spread this wrk ver 5 days but there are rles wrking 1-4 days per week with a steady increase in prprtin frm smaller t larger days wrked. 59% wrk in ne practice, 27% wrk acrss tw practices, 6% wrk acrss three practices, 4% in 4 practices, 2% in 5 practices and with 2% reprting wrking in up t 6 practices. The mst ppular mdels shw that majrity f CPs are wrking 4-5 days ver 1-2 sites. Participants reprted being registered as a pharmacist between 1978 and The majrity registered mre recently with several nly registering demnstrating that this scheme is clearly attractive t recent graduates. 74% f thse in pst are Independent Prescribers and a further 23% are currently wrking twards being Independent Prescribers. A large prprtin achieved their qualificatin in recent years including a large number in 2017, suggesting this scheme is cntributing t the upskilling f the prfessin. Participants were asked t cmment n their previus wrk histry and while a large prprtin has sme backgrund in cmmunity pharmacy, it is nt a simple picture. Directly befre taking up the CP rle 20% were hspital pharmacists, 16% were already wrking in GP practices, 15% were CCG pharmacists and 15% were ding ther things which were very varied and included several wrking in industry r prisns. There is evidence f bth pre-existing partnerships between GPs and pharmacists being built upn, as well as new relatinships being built. 25% had a relatinship with the pilt site prir t the applicatin but 12% had n relatinship and mved ver 50 miles t take up the pst. Clinical Pharmacists gave a wide range f reasns fr participating in the Natinal Pilt scheme including: New challenge persnally New challenge prfessinally Mre suitable / flexible than current rle (n weekend wrk ften cited, part time pssible, better fr families) Frustratins un current rles (cmmunity, hspital, CCG) Maximise use f skills Had IP qualificatin but had lacked pprtunity t use it Wrk mre clinically Career prgressin and develpment T cntribute t the develpment f the prfessin Imprve patient care (including specific references t plypharmacy, mental health Wrried abut cmmunity pharmacy as a wrking envirnment Sme were already ding the jb and this was natural prgressin r pprtunity fr them t develp (sme int senir rles) Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 47

49 Perspectives n Inductin, mentring and training Inductin experiences were very varied with 13% having n inductin perid and 6% having a ne day inductin. The average was 4-5 days fr 16% f peple r 2 weeks fr 31%. Inductins included a wide range f tpics but mst peple did sme shadwing and IT training. Only 1-2% reprted inductins t lcal netwrks. 20% are line managed by a senir pharmacist and 20% by a GP but 30% by a practice manager. 8% have mre than ne line manager. (One pharmacist reprts having 2 practice managers and 2 GPs). A large prprtin f CPs reprt the triangular mdel f line management where business management and guidance is prvided by the Practice (r federatin) Manager and clinical management prvided by a GP (r ccasinally a Senir Pharmacist r Nurse). GPs are reprted as ding 78% f mentring with Senir CPs nly 16%. 4% f CPs says they dn t have a mentr. 41% dn t have frmal time allcated fr training and mentring and fr mst CPs time allwed fr training is variable. Fr 20% f peple it is 1-2 hurs per week. (Sme participants talk abut 28 days allcated fr training but it is nt clear if this is the CPPE training nly. Smene else described a training pathway f 18 days ver 18 mnths.) Cmments abut inductin, training and mentring suggest that Mentring mdels aren t universal Senir CPs aren t as invlved as they culd be Existing relatinships can speed up the prcess f learning Rle utputs quickly take pririty ver mentring Inductin is imprtant fr belnging and integratin which suffers if this is nt priritised Where a frmal inductin is prvided it is appreciated and prvides a gd grunding fr future learning and relatinships Expectatins and assumptins abut pharmacists knwledge f primary care can be detrimental t prviding the supprt and training required Smene suggested buddying scheme / peer mentring wuld be useful Frmal guidance n inductin and mentring culd supprt the implementatin f future iteratins f the scheme: Althugh a GP supervisr was nminated a few mnths int my rle, I did nt receive structured supprt frm the practice fr the first 6-9 mnths due t lack f mentr engagement r cmmitment. This was attributed t business and varius business pririties in the practice. While I appreciate the challenges presented in prviding scheduled ne-t ne time, I feel this lack f in-huse supprt has dented my cnfidence in this rle and my place in the team, and impeded my integratin and clinical grwth. While I am able t perfrm my tasks effectively, it has been largely due t getting n with things n my wn and netwrking with ther pharmacists at events t gauge my next steps. Based n my persnal experience, I feel it is imperative when starting a rle that is nt clearly defined r new t the practice that there is in place smene within the team wh is enthusiastic and cmmitted t wrking with the pharmacist t help them develp the skills required t cntribute effectively t the practice's needs and embed their rle, akin t a GP trainer and registrar relatinship. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 48

50 When asked abut the mst useful training they had undertaken in relatin t the rle CPs reprted a wide range f pprtunities including: Lcal training (wide ranging and varied, ften hsted by practices) IP training and mentring Anticagulatin Acute illness in primary care (3 days) / Minr illness Red Whale / Mrph Cmmunities with ther GP pharmacists CPPE 4 day residential inductin GP mentring Lcal Universities specialised training When asked hw training culd be imprved, Clinical Pharmacists gave sme useful insights that culd cntribute twards the develpment f future training including: All learning t be undertaken in cntact time n time available fr additinal r preparatry learning Shuld be taught by peple wh wrk in General Practice Needs t be specific (e.g. hw t cnduct a review fr a specific cnditin) Shuld be clinically fcused (less leadership mre clinical cmes up a lt) and lead t develpment f advanced clinical skills Early residential shuld be clinical nt frm filling Use OSCE assessments t mnitr clinical training utcmes Senir Pharmacists shuld be mre invlved Streamline training s accessible t all Lndn nt accessible t all Inductin pack Train GPs and practices t / mnitr lcal mentring Imprve / ffer practice sftware systems specialised training (cding, templates, cnsultatins) Training in NON patient facing tasks needed e.g. discharge, tests, stcks, letters Change t shadw smene already in the rle Calendar f training events t be prvided early t enable practices t plan cver / clearer planning, structure and rating f training Set KPI targets fr mentrs Link t RCGP training / mre Red Whale Develp a training hub (use pilts t infrm) Dn t try t d t much the whle f AMR in a tw hur sessin impssible A cmmunity f practice is vital sharing experiences with ther GP pharmacists has been the mst valuable Develp a set f cmpetencies t wrk twards ne fr GP Pharms and an advanced clinical and mentring practitiner qualificatin fr senir CPs Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 49

51 Wrk tasks and priritisatin Wrk tasks are evenly managed with a third managing their wn tasks, a third being directed by a GP and anther third being directed by a PM. The rest were split. In sme cases a team apprach t the rle, lts f peple being steered by the CCG wh are paying fr the rle, and a few directed by receptin staff. The amunt f time spent facing patients in the rle varies enrmusly frm 1-100%. 2% reprt undertaking n patient facing rle. The largest prprtin f respndents spent slightly less than half f their time in pst patient facing. Figure C-2. Prprtin f time spent in patient facing activity 13% started patient facing wrk within the first week, anther 31% in the first mnth and anther 33% in mnths 2 and 3 shwing that the rle can develp quickly int patient facing wrk. This sectin f the data shws the pharmacists are mstly invlved in a wide range f tasks 38% undertake medicatin reviews in persn every day and 30% several times per week. Only 3.3% never undertake med reviews. Fr 70% this is a majr part f their rle 28% undertake medicatin reviews by phne every day and 27% several times per week. Only 6.5% never undertake telephne med reviews. Fr 49% this is a majr part f the rle 33% manage lng term cnditins every day and 28% several times per week. 10% are undertaking nline cnsultatins and 3.5% call this a majr part f their wrk Over 50% give lifestyle advice every day and 65% see this as a majr part f their rle 50% never d hme visits and anther 20% rarely s this is an area that culd be develped. There are similar data abut care hme visits 63% ding discharge review every day and 21% several times per week 80% dealing with prescriptin queries every day 75% respnding t clleague queries every day 35% use the PINCER indicatrs t supprt their rle Cst effective prescribing practiced by a lt f CPs Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 50

52 Lts f ther tasks including: Anticagulatin Telephne triaging Palliative care Audits Efficiency tasks DMARDS Training / MDT develpment Blds (interpreting tests and acting n) Lnger and flexible appintment times are cmmn. Patients are referred in t see the CP frm a range f rutes which can include a range f ther staff referrals and usually includes receptin triaging med reviews and prescriptin queries int the CP. Pharmacists reprt the greatest benefits they perceive frm wrking in Primary care t be: Medicines / prescribing safety / patient safety / reduced prescribing errrs / reduced risk / reducing medicatins related admissins Releasing capacity fr GPs (prescriptin queries and med reviews) Link between primary and secndary care Increased patient access t clinicians Stp n lnger needed medicines / minimising waste / ratinalising medicines use / reductin f benzdiazepine and piate prescribing / fcused deprescribing fr certain grups e.g. the elderly Management f lng term cnditins /dealing with plypharmacy Imprved medicines use and adherence / ptimising therapy Better mre specialised use f each prfessins skills Pharmacist expert advice in medicatin chice, use and review Imprved patient utcmes Reduced hspital admissins Reduced prescribing spend Better patient care and fllw up e.g. n patients prescribed antidepressants Lnger patient cnsultatins means mre hlistic care Public health educatin / Empwering patients t better self-care / lifestyle chices Better chesive wrking between prfessins / Specialised medicatins supprt fr the practice and clleagues Saving the NHS mney with fewer dctrs prviding care Supprting public health / signpsting t cmmunity pharmacy Sme examples f the cmments given: Saves GP time. Greater meds safety. Identifying and mnitring risky prescribing and inapprpriate prescribing. Drug safety re: mnitring. Better lng term clinical care prvisin. Saving NHS mney with fewer Drs prviding the care. Better chesive wrking between prfessins Mre streamlined prcess fr managing repeat prescriptin requests. Overall increased patient safety frm medicatin by increasing awareness amngst clleagues f drug safety, eg DMARD mnitring etc. GPs feel their prescribing has imprved bth clinically and cst effectively since having a clinical pharmacist in pst. Patients have anther HCP t see wh is able t fcus predminantly n their medicatins, yet are highly skilled and able t advise n ther aspects f their care and prvide lifestyle advice medicines safety/ ptimisatin/ cst efficiencies. NICE implementatin; additinal hcp delivering flu vaccinatins; additinal time t increase patient understanding/ adherence t treatments with ability t adjust in patient centred way. Frmulary adherence. Revising script Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 51

53 pathways fr repeat prescribing efficiencies. Increase in ETP uptake. Bringing expertise acrss wide range f LTCs t supprt patient care & GP wrklad eg. respiratry reviews; hypertensin; sexual health; medicatin queries. Relatinships and Satisfactin Pharmacists were asked t rate a series f statements relating t hw they wrked and relatinships with thers. The majrity f pharmacists reprted a very psitive utlk n their rle. 89% agree r strngly agree that they enjy wrking in their rle 89% agree r strngly agree that they wrk autnmusly in their rle 68% agree r strngly agree that they wrk innvatively in their rle 87% agree r strngly agree that they can wrk flexibly in their rle 87% agree r strngly agree that they wrk clsely with thers in the practice 89% agree r strngly agree that they are accepted by ther prfessinals in the practice 70% agree r strngly agree that they wrk clsely with thers in cmmunity pharmacy 29% agree r strngly agree that they wrk clsely with thers in hspital pharmacy 69% agree r strngly agree that they wrk clsely with pharmacists in ther practices 66% agree r strngly agree that they wrk clsely with CCG/MMT 39% agree r strngly agree that they wrk clsely with ther nn GP care prviders 65% agree r strngly agree that is it imprtant fr them t be actively researching as part f their rle (nly 10% disagree r strngly disagree) What helped integratin frm the CP perspective: Psitive attitude frm practice staff especially practice managers Understanding practice pririties Previus experience with primary care / the practice / the lcal patients fr pharmacists and with pharmacists fr the practice Shadwing Sitting with clleagues in a main ffice / receptin ffice Netwrk with everyne Bringing in chclate cake Time t learn Practice meetings and PLT sessins / CCG meetings / MDT meetings / PPG meetings A cmmunity f practice / netwrks with ther pharms / sharing experiences with ther CPs / regular meetings with thers / help frm peers / learning sets / WhatsApp grup with ther CPs Being practive / using initiative Being hnest abut strengths and limitatins Learning t say n Leaflet fr patients abut the rle /website shwing CP at the practiced / Newsletters Buy in frm ne r tw GPs gives yu the space t prve yurself t the thers / GPs wh are invlved frm the applicatin stage Making suggestins that imprve efficiency and safety High level supprt at inductin e.g. Clin Murray facilitated 4 sessins which really allwed the senir persnnel acrss the practice t better understand my rle and help t embed it. Creating a written 'paragraph' fr frntline staff t use t describe my rle t patients was valuable. Giving elevatr pitch t all staff helped/ and what my rle was in terms f their wrk navigatin. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 52

54 What hindered integratin frm the CP perspective: Clarity arund the rle e.g. GPs and practice staff unsure f the rle / benefits / the pilt scheme A lack f clear rle cmpetencies GP expectatins f clinical capabilities / mentring GPs nt being invlved at bid stage s n plans fr mentring r wrk streams Peple thinking I wrk in the pharmacy when called in fr an appintment Wrries abut litigatin e.g. (ne persn nt allwed t d flu jabs) Relatinships e.g. Lack f cntact with a senir CP Egs peple with their wn agenda Resistance t change frm sme staff Wrkplace culture GPs and nurses wrk alne / in sils / in wn rms Nt being included in lists e.g. fr GPs r nurses GPs time very limited fr mentring Shrt hurs in part time rle means lack f cntinuity / time cnstraints f part time wrking High vlume f study days away frm practice Mre practices takes lnger t integrate especially if less time spent in each (cmment prvided by a pharmacist wh reprted wrking acrss 5 sites) T busy fr learning / reflectin / time pressures / training feels impsed Different pressures and ideas frm different grups The quality and safety f medicines has little financial value i.e. it s nt in QOF I m n lw pay but have high respnsibility Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 53

55 Pilt site lead participants Pilt site leads emerged as a grup f stakehlders f significant imprtance since they act as gatekeepers t the Clinical Pharmacists and sites invlved in the pilt scheme. The data cllected frm the pilt site leads reflects similar key categries t the data cllected frm Clinical Pharmacists t allw cmparisns t be made. Data is presented in key areas as per the previus sectin site cnfiguratin, inductin mentring and training, relatinships and wrk tasks with additinal categries f lcalised pririties and lcalised evaluatins. Sme site leads shared their survey link. It was nt pssible t identify a single respnse that culd be taken t represent the multi-cmpletin sites. Data were therefre taken as prima facie withut exclusin. Demgraphics Demgraphic infrmatin (Table C-3) abut participants suggests a less diverse wrkfrce f pilt site leads than the Clinical Pharmacists wrking in GP practices. There is wide range f variance in age, gender and ethnic backgrund f staff these psts. Apprximately 70% f psts are held my females (same as CPs). Only ne persn managing a scheme is under the age f 35 a significant difference frm the CPs. 88% f pilt site leads are White British (while nly 53% f CPs are White British). Frequency (Percent) Gender Female 35 (71.4) Male 13 (26.5) Other 1 (2) Ttal 49 (100) Age Grup Under 25 1 (2.1) (14.6) (14.6) (14.6) (22.9) (22.9) (8.3) Ttal 48 (100) Ethnicity English / Welsh / Scttish / Nrthern Irish / British 42 (87.5) Irish 1 (2.1) Any ther White backgrund 1 (2.1) Indian 2 (4.2) Pakistani 1 (2.1) Chinese 1 (2.1) Ttal 48 (100) Table C-3. Demgraphic characteristics f site lead respndents Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 54

56 Site cnfiguratin The rle f managing the scheme lcally falls t different prfessinal grups with the majrity being business managers (Table C-4) Frequency (Percent) Business Manager / Directr 25 (48.1) Clinical Manager / Directr 5 (9.6) Senir Administratr 2 (3.8) GP 3 (5.8) Pharmacist 10 (19.2) Practice Manager 2 (3.8) Prject Manager 3 (5.8 Cntract Manager 1 (1.9) Head f Operatins 1 (1.9) Ttal 52 (100) Table C-4. The prfessinal backgrund f pilt site leads Half f the pilt site leads are emplyed at a practice with the thers spread acrss varius rles. (Table C-5) Frequency (Percent) GP practice/s 28 (53.8) CCG 2 (3.8) Medical services cmpany 2 (3.8) Other cmpany 13 (25.0) Self-emplyed 1 (1.9) Other 6 (11.5) Ttal 52 (100) Table C-5. Emplying rganisatin f the site lead Half f all pilt site lead respndents were invlved in the scheme frm the planning and submissin f bids but half jined at a later stage. (Table C-6) Frequency (Percent) Planning - I was invlved frm the planning and applicatin stage 26 (50) Recruitment - I was invlved frm a pint after the applicatin was 12 (23.1) submitted but befre the CP(s) was in pst Operatinalisatin - I was invlved after the CP was recruited but at 3 (5.8) an early stage in the scheme Management - I became invlved nce the scheme was peratinalised lcally 8 (15.4) Other 3 (5.8) Ttal 52 (100) Table C-6. Pint at which site lead assumed respnsibility fr management f the pilt Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 55

57 There were a range f mtivatins fr sites participating in the prgramme based n sme f the difficulties in primary care and sme f the ptential f pharmacists (Table C-7) Frequency (Percent) Difficulties in recruiting GPs 37 (71.2) Difficulties in Primary Care recruitment generally 27 (51.9) Difficulties meeting patient demand fr appintments 32 (61.5) Recgnitin f the benefits that CPs can bring t Primary Care 43 (82.7) Recgnitin f the need fr a specialist in medicatins 22 (42.3) Table C-7. What were the driving factrs behind yur lcal applicatin t the CP pilt scheme? There is very wide variance in the number f GP practices included at each Federatin site (Table C- 8). The average number f GP practices at each site is 7.6 (althugh this is skewed by larger numbers and there were far mre Federatins cmprising smaller numbers f practices). There was wide variance in the number f General Practices within each Federatin pilt site. 14% f all sites included 1 practice, but 6% invlved clusters f mre than 20 practices. N. f GP Practices Frequency (Percent) 1 7 (14.3) 2 6 (12.2) 3 3 (6.1) 4 0 (0) 5 5 (12.2) 6 7 (14.3) 7 4 (8.2) 8 4 (8.2) 9 1 (2.0) 10 1 (2.0) 11 1 (2.0) 12 3 (6.1) 15 1 (2.0) 18 3 (6.1) 22 2 (4.1) 27 1 (2.0) Table C-8. Number f GP practices that hst CPs acrss the pilt site Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 56

58 Numbers f Clinical Pharmacist psts There was equally wide variance in the number f Clinical Pharmacist psts recruited by each Federatin pilt site (Table C-9). 27.5% f sites emplyed 1 pharmacist, while 15.7 % f sites emplyed 4 CPs and the same prprtin emplyed 5 CPs. 2 sites emplyed 21 pharmacists. N. f CPs Frequency (Percent) 0 2 (3.9) 1 14 (27.5) 2 7 (13.7) 3 3 (5.9) 4 8 (15.7) 5 8 (15.7) 6 3 (5.9) 7 1 (2) 8 1 (2) 9 1 (2) 10 1 (2) 21 2 (3.9) Table C-9. N f CP psts funded per pilt site. N. f SCPs Frequency (Percent) 0 6 (12) 1 32 (64) 2 5 (10) 3 2 (4) 4 1 (2) 6 3 (6) 14 1 (2) Table C-10. N f SCP psts funded per pilt site. 64% f sites emplyed 1 senir CP (table C-10). 12% f sites reprted emplyed n senir CPs (likely t be single CP sites) When asked why this mdel f pharmacists, senir pharmacists and general practice sites was chsen, respnses were wide ranging highlighting the diverse nature f the schemes in the pilt phase. Many respndents suggested they used best estimates related t capacity and structures required. Often decisins were made based n ppulatin acrss sites and numbers f practices t be cvered, as well as pharmacist availability. Several respndents suggested financial mtivatins fr their chice f mdel relating t making best f funding, affrdability and participating practices willingness t pay. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 57

59 Many respndents related mdels t the rati f pharmacists t senir pharmacists and suggested using the guidance rati prvided by NHS England f 1:5. Others chsen alternative ratis related t their persnal lcatins e.g. sites, 2 CPs, 1 SP / 2CPs: 1SP / 2 senirs t 5 junirs / 1:6x2 / 1:4. Only ne respndent referred t rati f CP: Patients and suggested they were aiming fr 1: The evaluatin acknwledges that the pilt scheme did nt limit applicants t the 1:30000 (CP:Patient) rati used in later iteratins f the scheme. Table C-11 prvides a breakdwn f the CP FTE:Patient rati. The numbers f patients reprted acrss pilt sites varied enrmusly frm 10, ,000. At the smallest end f scale 11 sites have a ttal number f patients less than 30,000, whereas at the largest end f the scale 6 sites have upwards f 100,000 patients. Figure C-3 graphically illustrates the ratis emplyed by sites. Within this pilt phase there is clear preference fr a rati f patients fr each whle time equivalent. Number f patients per FTE Frequency Table C-11. N f Patients per FTE f CP Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 58

60 Figure C-3. Graphical representatin f the number f patients per FTE f CP Perspectives n Inductin, mentring and training Recruitment A variable number f applicants fr each rle, 30% f sites with 10 r mre applicant, 35% f 5-9 applicants and 35% with 4 r less. (Table C-12) Frequency (Percent) Mre than 25 applicants 2 (4.3) applicants 12 (26.1) 5-9 applicants 16 (34.8) 2-4 applicants 14 (30.4) 1 applicant 1 (2.2) Fewer than ne applicant per rle 1 (2.2) Table C-12. N f applicants per rle The quality f applicants was als variable with 54% high r very high but 40% average and 6.6% belw average. (Table C-13) Frequency (Percent) Very high 4 (8.9) High 20 (44.4) Average 18 (40) Lw 2 (4.4) Very lw 1 (2.2) Table C13. Quality f candidates applying fr each rle Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 59

61 There are quite high levels f turnver with 15 sites reprting turnver f at least 1 CP pst, and 5 sites reprting turnver f 1 GP practice and 10 sites reprting turnver f mre than 1 GP practice. Cmments n recruitment were wide ranging and made a number f recmmendatins. Several respndents suggested it wuld be helpful fr cnsistency acrss sites, ne suggesting a universal recruitment prcess facilitated with input frm a senir CP. (Other respndents suggested that pharmacists shuld be invlved in recruitment). One site reprted successful central recruitment with practices invlved in interviews. Several made cmments that while the CP wuld be lcated at the practice it was ften the Federatin wh was respnsible fr recruitment and therefre effrts shuld be made t invlve practices in the prcess fr early buy in. One respndent reflected n a high level f turnver impacting the ptential impact f the scheme at his site. Reflectins n inductin Reflectins n the inductin prcess by pilt site leads ffer useful insights fr future planning: Sites ften used the prcess applied t ther staff We used ur usual inductin prcess fr nn GP clinical staff Sites gave examples f cmpnents they felt it useful t include. These can prvide useful guidance t thers. Shuld shadw a senir pharmacist, wrk in lcal pharmacy and wrk t a set inductin scheme relevant t pharmacists Imprtant t be thrugh Cmmunicate with practices and then cmmunicate again - explain that this is a training/develpment rle and that will take time t shw benefit - the mre input frm practices the mre they will get ut - sme d expect a fully develped service frm the start As an rganisatin we have ur wn structured inductin prcess which we augmented by having a PIGP inductin schedule. Wrking at scale acrss numerus practices has helped us develp that further A lt f supprt has been necessary frm all members f the primary care team, including GP time It was useful t have the CP shadwing all members f staff and the clinical team in the practice s they fitted well int the team, understd what everyne's rle was, wh t g t fr help etc. Als this gave each member f the practice team an idea abut what the pharmacist wuld be ding We rtated the CP fr the first 2 weeks f inductin arund GP's & Nurses sitting in cnsultatin with patient cnsent, they then sat in with the receptin team discussing & assisting with prescriptin queries. Fllwed by spending time with the Practice Manager fr an verview f hw the practice wrks and with the QOF lead. Sites gave examples f experiences which had nt been beneficial The CPPE inductin prcess was quite inflexible, which led t ur first senir CP leaving her rle early during the prbatinary perid The inductin via CPPE & the pilt had nt taken int accunt what wuld be the mst apprpriate wrklad that a CP wuld undertake (i.e. Practice Nurse/HCA tasks are inefficient t be cmpleted by CP at 2-3 times the cst) als indemnity nt in place fr diagnsis Given the pressure fr the CPs t start t cntribute t managing pressures in the practice, their inductin was t shrt and insufficiently cmprehensive I think we culd have intrduced the CPs a little bit better s the whle team, clinical and nn-clinical culd recgnise they [sic] skills sner. Initially the inductin prcess was arund wrking clsely with GP and therefre it became islated Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 60

62 Sites suggested guidance fr cnsistency in inductin wuld be beneficial It is useful if they all have the same inductin if they are wrking in ne area, even if they are wrking fr different practices Sme sites gave examples that shwed the difficulty f allcating respnsibility between the Federatin, practices and ther partners The CCG had t use a federatin as we were nt allwed t bid, the federatin were appalling at the inductin and the CCG team had t step in t supprt the prcess t manage the initial expectatins frm practices. Reflectins n the training prcess Pilt site leads gave sme useful insights int their perspective n training with sme areas fr imprvement and suggestins fr develpments Time cnsuming fr pharmacists and practices / practices feel they spend t much time training Training prvided nt always beneficial / Needs t be tailred (especially fr mre experienced pharmacists) Duplicatin between prvisin (CPPE / IP) Lack f practical skills training utside practices Pilt site leads suggest that based n their wn experiences they feel the mst imprtant training needs fr incming pharmacists are; Understanding primary care (especially culture) Interacting with patients / cnsultatin skills Independent prescribing Lng term cnditin management Minr injuries / minr illness Time management Sftware training When asked t reflect n their wn training needs, many pilt site leads reprted feeling suitably trained fr their rle. Sme respndents recmmended that a brief wrkshps might be useful fr pilt site leads, and several tpics were suggested as suitable fr training wrkshps including; Brad intrductin t the rle / primary care demands / pharmacist cmpetencies Shared experienced frm ther sites Insurance infrmatin Leading and managing in a clinical (primary care) cntext When asked t reflect n the reprting prcess fr rutine service data, pilt site leads expressed that they were difficult t prduce and there were sme cncerns that the KPIs were nt apprpriate r may nt generate useful data. Several respndents reprted being unwilling r unable t prvide the rutine service data. There was sme frustratins expressed that the reprting prcess represented a ne way line f cmmunicatin with n feedback ffered frm NHS England in respnse t the data prvided. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 61

63 Relatinships with ther key staff Line management When allcating wrk tasks, line management varies significantly. 20% f CPs are fully autnmus and decide their wn wrk, 25% have tasks decided by GP and the ther half are split between Nurses, Practice Managers, Practice Management Grups, pilt site leads and thers such a s CCG r steering grup. Frequency (Percent) The pharmacists themselves 33 (63.5) Senir Pharmacist 25 (48.1) GP 43 (82.7) Nurse 7 (13.5) Practice clinical management grup 15 (28.8) The pilt site lead 10 (19.2) Other 4 (7.7) Table C14. Wh decides what tasks the CPs are expected t d as part f their rle (n=52). Multiple ptins may be selected s percentages reflect prprtin f respndents Wrk tasks and priritisatin Pilt site leads demnstrate clear understanding f the day t day wrk f the CPs 86% f pilt site leads reprt that med reviews are an essential part f the CP rle (this prprtin is the same fr bth face t face and telephne reviews) 60% f pilt site leads reprt that LTC cnsultatins are an essential part f the CP rle 92% f pilt site leads reprt that lifestyle advice is a part f the CP rle essential (53%) r ptinal (39%) 90% f pilt site leads reprt that discharge reviews is an essential part f the CP rle 92% f pilt site leads reprt that prescriptin queries are an essential part f the CP rle 98% f pilt site leads reprt that supprting clleagues is an essential part f the CP rle Arund a third (32%) f pilt site leads feel that care hme visits are an essential part f the rle but nly 8% feel that hme visits are an essential part f the rle. Pilt site leads suggest a wide list f ther tasks that their CPs is invlved in which include: Minr illness Vaccinatins Mnitring high risk medicatins Training prescriptin clerks and GPs in meds management DMARDs (Disease mdifying anti-rheumatic drugs) NOACs (New ral anticagulants) CCG Prescribing Clinical audits Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 62

64 Pilt site leads reprt the greatest benefits they perceive frm CPs wrking in Primary care t be: Prescribing Increasing patients,medicines understanding and adherence Addressing the supply-demand imbalance / capacity in Primary Care Offering a Quality (Better) service Patient safety Primary Care Team expertise and skill expansin All practices in ur scheme wuld n lnger d withut him; he is a vital member f the team and greatly appreciated by all. When invited t suggest what utcme measures may be apprpriate in relatin t the pilt scheme, the pilt site leads suggested a wide range f data. GP time saved Other clinician time saved CP wrklad (and hw that represents time saved fr thers) GP satisfactin Med reviews linked with utcmes Patient satisfactin survey Imprved cmpliance Numbers f qualified IPs Adverse events avided Avidable admissins Reductin in waste Lcal needs pririty Quantitative and qualitative N f times repeat prescriptins changed / ptimised CP prescriptin wrk nt invlving GP Safety Lcal pririties Several pilt site leads used the survey t reprt n hw they had persnalised the develpment f the pilt scheme accrding t lcal pririties. These insights culd prvide useful examples t ther areas f hw t maximise the benefits f the scheme accrding t lcal, as well as natinal, strategies and pririties. The survey ffered the pprtunity fr pilt site leads t share examples f lcalised practice and research. There are a wide range f examples and this reprt wuld recmmend time and investment t wrk with lcalised research agendas t maximise the lcalised research appraches, and t ensure that tp level verview is given in rder that lcalised data might be used fr natinal benefit. Sme examples f lcalised targets being mnitred included: Medicatin reviews Hypertensin reviews Frailty medicatin reviews Diabetes clinic Asthma clinics NOAC management NHS England KPIs Flu clinics Patient surveys Reducing piates n repeats Cntributin t prescribing gain share Unplanned admissins Multiple cmbinatins f the abve criteria Patient respnses t new rles Patient educatin Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 63

65 Impact n medicines ptimisatin and efficiency in clinical and administratin prcesses arund repeat prescriptin management Over half f all sites (58%) reprted cnducting lcal research and evaluatin. There shuld be further wrk dne t explre, understand and supprt this lcalised apprach t implementatin and evaluatin and ensure the pprtunity exists fr sites t share best practice appraches. Sme examples f lcalised research wrk utlined by pilt site managers include: Impact n care hmes Safer prescribing in frailty SCP and plypharmacy in ver 90s Audit f clinics Interventin lg f wrk dne mapped t salary grading t understand cst saving Breakdwn f cnsultatins and impact n ther staff Reprt cmpiled Reprt available Feedback frm practices and pharmacists Recrded CP wrkflw by type and vlume Hypertensin audit and review Overprescribing review We even fund patients selling their medicines n ebay IT tracking We are using a Read cde frmulary s can analyse wrk themes dne by pharmacists in practice Innvative practice We invited pilt site managers t describe any innvative practices ccurring at their site and at least half respnded t suggest that they felt the wrk undertaken at their site was innvative. Sme suggestins f innvatins in practice included: Site sharing We have 3 pharmacists that wrk acrss 2 sites and split their time between the 2. This allws fr sharing f ideas acrss the practices Lcalisatin f mdel at practice level We have a mix f mdels f emplyment. Larger practices emply a full time pharmacist themselves. Medium size practices share a pharmacist (emplyed by the practices) and the small practices have pted t use a lcal hspital trust t prvide clinical pharmacists t them. Each mdel has advantages and disadvantages Changing face t face t telephne reviews DMARDs Tracking better meds management cmplete review f prcesses and use f prescriptin clerk, leading t a 25% reductin in meds management csts in 3 mnths Partnerships / Wrking with thers e.g. Care Hme Wrk MDT wrk Links t hspital Dmiciliary care / wrking with cmmunity Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 64

66 Cllabratin We have a team based apprach with leadership frm a (nn-pilt) experienced clinical pharmacist. We wrk cllabratively with the lcal CCG and hspital and are develping relatinships with lcal cmmunity pharmacists We use a daily 10 minute huddle fr the primary care team t discuss patient safety issues as well as any ther cncerns These innvatins give a useful insight int the way sites are lcalising innvative practice. This evaluatin affrds the pprtunity t explre and disseminate example f innvative practice. This aspect f the evaluatin will be the fcus f the final stage f the research. 65% f pilt site leads r 29 Federatins are willing t engage with further research. The final sectin f the questinnaire gave pilt site leads the pprtunity t share practical feedback frm their experience f the scheme implementatin. When asked t share things that hindered integratin, the fllwing themes emerged: Time Lack f time fr develpment / Intensity f initial training CPPE/IP Nt being here every day / insufficient time in practice / high rati / patient ppulatin Cnflicting agendas Different agendas and expectatins between CP and Practice Practices wh dn t see ptential / GP dn t understand rle Level f clinical supprt & supervisin required fr CP t deliver n required tasks (increased rather than reduced wrklad fr GPs) HR issues e.g. Clinical pharmacist wh had integrated well leaving fr persnal reasns Senir CP being dismissed fllwing allegatins f harassment CP wishing t wrk in a manner which increases persnal stress CP cnflict with anther CP creating suspicin and cmpetitin rather than effective team wrking Lack f clarity arund level f supervisin required t facilitate IP training and qualificatin NHS England NHSE have been very pr in terms f cmmunicating / mnitring KPIs / Agreement with NHS England that funding t supprt the practices needs t be reimbursed in the first mnth f the pilt (practices were utstanding mnies fr up t 5 mnths) NHSE have nly hindered the whle prcess and feel we dn't need the middle man t facilitate the pilt and ther schemes Pr cmmunicatins Pr prject management Pr cmms, data capture and lack f prject management When asked t share things that helped integratin, the fllwing themes emerged: Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 65

67 Meetings Being invlved in meetings, training and being seen t engage with the team Quarterly meetings with pharmacists and GP trainers Attendance at practice meetings Regular steering grup meetings Mnthly meetings led by SCP fr all CPs Integratin range f methds I can't stress enugh hw imprtant it is fr the CP/SCP t be part f the practice team frm the utset. Integratin is key Inductin Wrk shadwing CP physically lcated in practice with clinical teams Mentring Pharmacist cnsistent in practices Planned investment time We invested 2 sessins f Lead GP time per mnth fr 6 mnths at the start f the scheme. This allwed the GP and pharmacist t get systems set up and in place, training t take place, prtcls t be reviewed, new schemes develped etc. e.g. Frailty Clinics fr cmplex elderly which included pharmacist input Practices cmmitted t develping pharmacists Lcally supprtive culture Gd cmmunicatin with the team and the expectatins and limitatins within the rle. Our practice team really like ur CP and want him t stay n permanently nce the 3 years f the pilt has been cmpleted Pharmacist attitudes Can d attitude Willing t have a learn and adapt Knwing wn limits Wider links and supprt Links t and supprt frm CCG MMT Links t hspital pharmacy teams Lcal netwrking and peer learning (utside CPPE) Appinting a senir CP t crdinate at the highest level and liaise Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 66

68 Clleagues participants CPs were invited t share a link with clleagues in their practice t cmplete a questinnaire. Respnses were received frm 63 primary care clleagues, 24 (39%) f whm were GPs Disclaimer: While we have this data it is minimal, and therefre while descriptive statistics are pssible, the relative imprtance f their findings shuld nt be misinterpreted. The prject steering cmmittee were hesitant t publish this data in light f the limitatins f such a small sample size. Qualitative cmments frm this dataset are likely t be mst useful. Nnetheless the data set is represented, as requested by the cmmissiner. Demgraphics Table C15 shws the breakdwn f the clleague respndents. Respndent rle GP Trainee Dctr Supprt team Practice manager Nurse Other Ttal Gender Female Male Prefer nt t say Ttal Age Ttal Ethnicity English / Welsh / Scttish / Nrthern Irish / British Irish Any ther White backgrund Bangladeshi Chinese Ttal Table C-15. Demgraphic characteristics f clleague respndents Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 67

69 Inductin, training and mentring Varius clleagues reprted being part f the CP inductin prcess, hwever it wuld appear that the majrity f inductin was cnducted by practice managers (Table C-16). Did/ d yu cntribute t Clinical Pharmacist inductin t the practice? Respndent sub grup Yes N GP 10 (41.7) 14 (58.3) Trainee Dctr 0 (0) 3 (100) Supprt team 3 (33.3) 6 (66.7) Practice manager 10 (58.8) 7 (41.2) Nurse 1 (14.3) 6 (85.7) Other 0 (0) 3 (100) Table C-16. Clleague respndent cntributin t CP inductin 58% f GPs wh respnded t the survey did nt cntribute t inductin. Thse wh did cntribute were invlved in a range f ways including: Helping t plan inductin Offered shadwing experiences Offered a mentring intrductin Directly supervised inductin Did/d yu cntribute t Clinical Pharmacist mentring? Respndent sub grup Yes N GP 13 (54.2) 11 (45.8) Trainee Dctr 0 3 (100) Supprt team 0 9 (100) Practice manager 2 (11.8) 15 (88.2) Nurse 1 (14.3) 6 (85.7) Other 0 3(100) Table C-17. Clleague respndent cntributin t CP mentring 54% f GPs wh respnded t the survey cntribute t mentring (but 46% d nt, Table C-17). A range f examples f mentring practices were given including: Regular weekly / daily updates Discussin f cases Patient rle play N prtected time but had her sit in with me I am part time s I cntribute when I can Infrmal / ad-hc Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 68

70 Did/d yu cntribute t Clinical Pharmacist training? Respndent sub grup Yes N GP 12 (50) 12 (50) Trainee Dctr 0 3 (100) Supprt team 0 9 (100) Practice manager 2 (11.8) 15 (88.2) Nurse 2 (28.6) 5 (71.4) Other 0 3 (100) Table C18. Clleague respndent cntributin t CP training 50% f GPs wh respnded t the survey cntribute t training (50% did nt). (Table C-18) What d GPs think are the mst imprtant training needs fr CPs? Understanding primary care / GP practices / lcalised ways f wrking Systems and prcesses f the practice Understanding phenmenal wrklad f General practice An understanding f hw General Practice wrks day-t-day and hw patients use it Stepping back smetimes frm what the patient requests, and what is actually crrect management. Nt always the same thing! Hw the current systems wrk in specific practice Understanding f practice script systems and CCG meds frmulary Understanding what a practice needs frm the pharmacist Knwing hw the repeat prescribing is dne Learning the system, lking at prescriptins and hw they are handled, learning searches Integratin f pharmacist rle with thse f ther clinical staff e.g. triage nurse, COPD/Asthma nurse, Diabetes nurse) t ensure best use f each ther's skills fr patients' needs Lcal understanding f CCG medicine management plicy An explanatin f hw we wrk in primary care, patients expectatins f a "new HCP in their practice, what ther GPs and staff might use a pharmacist fr, patient imprvement Regular cntact with a GP Ability t cntact a GP fr ad hc queries training in lcal cmputer use and plicies (e.g. practice prescribing plicies), intrductin t the team and areas f expertise Hw the individual practice systems wrk practice systems - cmputer and general plicies Differences between cmmunity pharmacist and GP rles. Expectatins n bth sides A clear understanding f what the practice needs are n the ne hand and a clear understanding f the knwledge and skills that the clinical pharmacist can ffer n the ther T help us in running the practice as a member f ur team with regards medicines management Risk management managing the high level f risk which we are used t in GP are prbably the biggest challenge Ensuring safety and supprt f the pharmacist's clinical decisin making when seeing patients ensuring that pharmacist has supervisry supprt fr clinical wrk when itis needed Balance f supprt & learning with safe service prvisin Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 69

71 Develping skills Reviews f medicines/patients. audits t imprve patient care Minr illness wrk Independent prescribing decisins Nn-medical prescribing. Wrking at yur cmpetency level establishing clinical educatin needs/training prgram early n (in cnjunctin with the CPPE pharmacist educatinal prgram) Understanding the hlistic apprach t patient care ensuring pharmacists fcus n what they are best ate medicines experts and d nt try t take n t many new skills initially - understand QOF Line management Clleague respndents reprted a wide range f line management structures (Table C-19) Persn managing CP GP Trainee Dctr Respndent grup Supprt team Practice manager Nurse Senir pharmacist 6 (6.00) 1 (10.0) 0 2 (2.00) 1 (10.0) 0 Other GP 10 (58.8) 0 3 (17.6) 3 (17.6) 1 (5.8) 0 Practice manager 2 (16.7) 0 3 (25.0) 6 (50.0) 1 (8.3) 0 They dn t have a line manager (100.0) They have mre than ne line manager (80.0) 1 (20.0) 0 I dn't knw 4 (28.6) 2 (14.3) 2 (14.3) 0 3 (21.4) 3 (21.4) Other 2 (50) (50) 0 0 Table C-19. Line manager f CP 58.8% f GPs reprt that a GP line manages the CP, 158.6% did nt knw wh the CP line manager was. Tw respndents reprted line management partnerships between the practice and the grup f sites. Shared between managing partner and emplyer (lcal scial enterprise) 35% f GPs suggested that a GP decided what tasks the CP is expected t d as part f their rle, where 11% suggested this decisin was with the senir pharmacist, 19% with practice managers, 3% with a nurse and 25% suggested that Pharmacists decided n their wn wrk tasks. 74% f GPs felt that the perfrmance f the CP was mnitred and 22% did nt knw if was mnitred. A wide number f measures were suggested as being in use fr mnitring the perfrmance f the CP including: Defining wh mnitred the CP perfrmance GP Mentr Senir Pharmacist A GP partner wh is als a trainer GP & Senir Pharmacist mnitr at practice level. There is a [lcality] wide grup that lks at all the CPs' wrk & NHSE mnitr KPIs By the CP, ur practice manager and the senir pharmacist By us as GPs/ur practice manager and her senir mentr. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 70

72 Defining the prcess fr mnitring perfrmance PDPR In-huse appraisal Thrugh regular scheduled review with practice Supervisr f his training at present, which will carry n after pharmacist cmpletes his frmal Prescribing Qualificatin and CPPE prgram. Als an annual staff appraisal will take place with practice manager and GP. Defining clinical measures fr mnitring perfrmance Weekly feedback, audit f number f medicatin reviews Templates recrding activity He cmpleted regular returns f his wrk Audits We lk at ur lists f tasks given t her and see hw these have imprved Pharmacists nt mini-dctrs We aren't 'expensive nurses' r 'cheap dctrs' we bring a wide array f unique knwledge and skills and a fresh perspective, valued by patients and allied prfessins (Cmment by CP in survey) As demnstrated earlier 70% f CPs suggest that medicatin reviews are majr part f rle etc. Medicines management (cst effective) 57.9% f GPs believe this shuld be a majr part f the CP rle 42.1% f GPs believe this shuld be a minr part f the CP rle Medicines ptimisatin (utcmes) 84.2% f GPs believe this shuld be a majr part f the CP rle 15.8% f GPs believe this shuld be a minr part f the CP rle 71% dn t knw hw ften their CP des this Data shws that CPs believe that diagnsis remains the wrk f the GP. 99% believe that GPs make a majr cntributin t diagnsis but nly 6.8 believe that CPs make majr cntributin and 18.5% believe that CPs make a minr cntributin t diagnsis. GPs supprt this with 92% believing GPs make the majr cntributin t diagnsis and 0% believing this t be a majr part f the CP rle. By cmparisn 57% f CPs believe that their rle make a majr cntributin t determining if new medicatin is needed, and 18% believe this t be a minr part f their rle. GPs seems t cncur with 27% believing this t be a majr part f the CP rle and 9% a minr part. GPs were asked t describe the innvatin the rle brught t the practice(s) and made cmments including: Excellent at driving cst effective prescribing and dealing with hspital discharges and pain clinic medicatins /epilepsy meds that need titrating/withdrawing Nt innvative, just cmmn sense, that she shuld have been in rle fr years/decades. excellent value fr mney and imprves patient medicatin care Shuld be really pushed. Excellent VFM Excellent scheme. Shuld be develped even further. I cannt be withut CP anymre. Please dn't stp the pilt Nt sure that it saves mney. e.g. mre and mre peple 'qualifying' fr ENSURE and fd supplements. Only beginning t have impact I think having practice based pharmacists is really helpful. Prbably they uncver a "can f wrms which needs srting ut but I think they make a valuable cntributin t reducing side effects, reducing hspitalisatins frm drug side effects, imprving cncrdance and changing patient's expectatins f wh is the crrect persn t see abut their medicatins Wrking well fr us and ur patients. Imprving quality f care and cst effective prescribing. It seems clear that bth GPs and CPs believe that the biggest cntributin CPs can make t primary care is in issues arund managing medicatin, rather than being used as mini-dctrs. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 71

73 Respndent grup GP (n=24) Trainee Dctr (n=3) Supprt team (n=9) Practice manager (n=17) Nurse (n=7) ther (n=3) Ttal CPs wrk autnmusly in the rle CPs wrk innvatively in the rle CPs can wrk flexibly in the rle CPs wrk clsely with thers in the practice CPs are accepted by the ther prfessinals in my practice CPs are accepted by patients as a healthcare prfessinal SD D NAND A SA SD D NAND A SA SD D NAND A SA SD D NAND A SA SD D NAND A SA SD D NAND A SA Table C-20. Respndent perspective n varius rle and practice related aspects f the CP rle. SD Strngly disagree, D- disagree, NAND Neither agree nr disagree, A agree, SA strngly agree Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 72

74 Respndent grup GP (n=24) Trainee Dctr (n=3) Supprt team (n=9) Practice manager (n=17) Nurse (n=7) ther (n=3) Ttal CPs wrk clsely with thers in cmmunity pharmacy CPs wrk clsely with thers in hspital pharmacy CPs wrk clsely with ther practices CPs wrk clsely with ther pharmacists in ther practices CPs wrk clsely with ther CCG r Medicines Management Team pharmacists CPs wrk clsely with ther nn-gp care prviders CPs wrk clsely with allied health prfessinals (e.g. physitherapists, dieticians) It is imprtant fr CPs t be actively invlved in researching the benefits f the rle SD D NAND A SA SD D NAND A SA SD D NAND A SA SD D NAND A SA SD D NAND A SA SD D NAND A SA SD D NAND A SA SD D NAND A SA Table C-21. Respndent perspective n cllabrative aspects f the CP rle. SD Strngly disagree, D- disagree, NAND Neither agree nr disagree, A agree, SA strngly agree Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 73

75 Summary A significant number f respndents shared their views with the evaluatin team. Respnses suggest that there are a wide range f activities ccurring in practice. The backgrund f pharmacists in the pilt is brad bth frm and age and ethnicity perspective. The prprtin f time pharmacists spend in patient facing rles is highly variable frm nthing t almst full time. Overall the training prvided with the pilt has been useful, but timing and cntent had meant that individual pharmacists have nt gained as much as might have been pssible. Mst pharmacists recgnise that they have gd relatinships with the MDT including clleagues in ther areas f pharmacy. Mst pilt sites have pted fr a rati f CP FTE:patient far belw the GPFV plan f 1:30 000, with the majrity pting fr 1: r less. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 74

76 Appendix D External stakehlder perspectives - Overview f SWOT data Intrductin The research cmmissined was t engage with stakehlders invlved in the pilt phase f the Clinical Pharmacists in general practice scheme. Data cllectin methds were bth planned and emergent, in rder t respnd t arising circumstances. The stakehlder day rganised by CPPE and Health Educatin England (HEE) in May 2017 ffered a unique pprtunity fr the research team t engage with key stakehlders frm the pilt scheme and gather research data. Stakehlders attending the day represented a wide range f gegraphic as well as jb rle and level diversity. Attendees (n=80) included bth n the grund rles such as CPs in the rle, pharmacists in a range f wider rles, GPs and Pilt site leads, as well as representatives frm mre strategic rles representing rganisatins such as gvernment, universities, RPS, CPPE, HEE, Ryal Cllege f General Practitiners (RCGP) and thers. Tw key data cllectin methds were used t generate feedback frm key stakehlders n the scheme s far. Bth methds utilised a SWOT analysis apprach t ensure representatin frm all areas f the scheme including strengths, weaknesses, pprtunities and threats. This is a technique utilised in a range f scenaris (Helms and Nixn, 2010, Jacksn et al., 2003, Picktn and Wright, 1998) The first methd invlved the cmpletin f a paper based SWOT analysis, asking stakehlders t respnd t these key areas relating t the scheme at three levels patient, practice and plicy. The paper based exercise was distributed t all stakehlders attending the event and cllected at the end. Thirty three cmpleted SWOT analysis were cllected representing 40% f participants. Data was cllected in a database, analysed thematically and tp level findings are presented in this reprt. The secnd methd invlved stakehlders attending fcus grup interviews facilitated by the research team t discuss stakehlder views n the SWOT f the pilt scheme. The ttal number f interview participants was 31, split int 4 grups each f participants. Fcus grup participants included participants frm bth n the grund and strategic rles. Data was recrded and transcribed verbatim and analysed accrding t the SWOT framewrk. Current thematic analysis in in prgress and will infrm the final reprt. The SWOT demnstrates that participants recgnised a brad range f strengths f the scheme including the welcme f dedicated funding t supprt clinical develpment in primary care. Participants als recgnised that the pilt had imperfectins and these shuld be given cnsideratin prir t further rll ut. The SWOT analysis is able t represent the key strengths, weaknesses, pprtunities and threats f the scheme frm stakehlder engagement at the interim pint f the prject. Questinnaire data is represented at three levels in table D-1. The interview data analysis frms the sectin f external stakehlder perspectives. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 75

77 Strengths Weakness Opprtunities Threats Plicy Macr level develpments Gvernment Respnsible bdies Strategic planning Practice Micr level develpments On the grund Operatinalisatin General Practice Clinicians Patients Outcme level develpments Impact Service level Cncept Cmmitment thrugh lng term strategies Multi-agency cmmitment Funding Training Efficient use f existing expertise Capacity release MDT enhanced skill mix Expert medicatins knwledge Patient benefits Embedding pharmacists in general practice Rle flexibility Relatinships Training Lnger appintments / mre hlistic care Imprved capacity / access Medicines expertise Safer prescribing Active deprescribing Better patient utcmes GP Supervisin Staff and site turnver Mdel / Lack f flexibility Pr r n links t cmmunity pharmacy Training Shrt term planning Cmmunicatin Funding N evaluatin data Patient awareness/educatin Missed pprtunities fr early learning Develp GP supervisin Cmpetencies unclear Lack f rle definitin Lack f cmmunity Lgistics Mtivatins Unclear KPIs Patient understanding f primary care rles Lack f existing knwledge Lack f awareness f pharmacist skills Incnsistency in clinical supervisin Lack f QA prcedures Table D-1: Summary Tp level analysis f paper based SWOT analysis with pilt phase stakehlders New ways f wrking Learning MDT Practice level plicies Grwth and develpment f Pharmacy Prfessin Funding Better patient care Shared learning Research and impact Ptential t imprve patient access and patient care Integratin PPGs Increased adherence Increased ptimisatin Better care fr LTC Better care n discharge Reduced A&E admissins Quality imprvement Better patient educatin and self-care Better patient utcmes Prmte cmmunity pharmacy Gvernment and plicy changes Lack f learning Operatinalisatin Rati Finance Mismatch f expectatins Negative impact n team Creating labur market tensins External pressures Finance Sustainability Unclear rle definitin Risk f errr Resistance t change (patients / practices) Optimisatin driven by cst agendas nt patient care Hw t demnstrate added value and cst effectiveness f pst

78 External stakehlders Strengths Plicy level strengths Stakehlders generally viewed the scheme psitively and it was part f the GP Frward View it was frward lking, legitimate, recgnised, and patient fcussed and fully funded including the training. The multi-agency apprach has wrked well. There is gvernment representatin arund medicine ptimisatin and agenda, t describe that, where they want t be, what they want it t lk like. I think 10 years ag they might have struggled t describe it (CCG representative) S in terms f strengths I think this des integrate with the plicies which is great, but als I think it has a patient service fcus. It s nt every innvatin r plicy initiative which is actually fcused n enhancing patient service. (GP with CCG wrkfrce rle) I think at the time f dismal view in the cmmunity pharmacy sectr particularly, I think it has been a really psitive drive/push twards using skills (CCG representative) Training The CPPE pathway was seen by sme as a very psitive develpment althugh there was sme debate abut summative assessment and whether there shuld be a certificate n cmpletin. we have had smebdy taken n a jurney t get t where we are nw, where we have never been befre, I think is still an amazing achievement (Pharmacist) I think this is the first time that I can recgnise that there is actually a reasnable infrastructure been put in place, supervisin f pharmacists in training in primary care and I think that is great. We dn t want t let that g. The HEE quality framewrk, we need t use that as a mechanism t try and bed this in s that anything else, yu knw we have always dne pharmacy training n the cheap, peple say we gt this frm CPPE, divide that by the number f pharmacists and technicians, it s peanuts. Fr nce smebdy is paying fr a bit f infrastructure and I think that is great. (Prfessinal bdy representative) Practice strengths Practices had in general adapted very well t having pharmacists and valued having pharmacists as part f the team. They were saving GP time. At the practice level, I think actually ne f the strengths is arund practice emplyment element because it gives practice emplyment wnership and respnsibility. Then yu wuld envisage that within the 4 years they wuld begin t see enugh value in the rle that they wuld then want t emply them full time themselves. (Academic) Pharmacists are saving GP s time, better skilled wrk and it is nt just abut parachuting pharmacists int practice, it is abut gvernance and utilising each member f the multi prfessinal team in the best way. That seems t be happening as these rles start t embed. (Pharmacist) Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 77

79 GP wrklad There was a psitive Impact n the GP wrkfrce and there was a feeling that caselads were mre manageable and that peple were wrking in an envirnment that is functining. if it relieves pressure n ther prfessinals within the practice, r makes wrking generally mre harmnius r different, thse kind f imprving peples wrking lives, then actually that may mean that the GP that was ging t retire in the next 12 mnths says actually I will stay n anther cuple f years, r that type f thing can start t happen. (CCG representative) I had a cnversatin with a GP and his ambitin abut having a pharmacist in his practice was ging hme at 7pm at night ppsed t 8pm..(CCG representative) We all knw that everyne fire fights but just t feel like yu are ding a better jb as a team, taking care f yur patients, I cmpletely A that feeling at the end f the week. As smene said tday that feeling f satisfactin, less a degree lwer f stress that is a huge imprvement if that were t happen, it is nt t be belittled. (CCG representative) Pharmacists wh were in ne practice every day were able t have a huge impact by making incremental changes every day. Cmpared with thse wh drpped in fr half a day. It had wrked well when pharmacists are already independent prescribers and can have a patient case lad. Otherwise they have ften taken n medicines management duties until they became IPS. Participants warned against criticising the prject at this time as it will take time fr the pharmacists t becme embed in general practice. They gave examples f pharmacists wh had wrked in practices fr years, wh were part f the furniture and made a massive difference t patient lives. There was a perceptin that the prject had wider influence utside f General Practice fr example as 60% came frm cmmunity pharmacy there was a better understanding f challenges and pprtunities t prviding the best primary care pssible. Practice relatinships within CCG had changed thse wh had a pharmacist nw had smething in cmmn, the pharmacists, had made them talk t each ther mre. Patient strengths Patients were happy t cnsult pharmacists nce they knew what they were capable f. They liked the extra time and they were als liked cnsultatins with independent prescribers. They like the extra time, I think it is making a difference as we have heard t the utcme f using their medicines crrectly, it is helping t reduce wastage. I haven t heard any negative apart frm at the beginning when patients were uncertain as t what pharmacist culd d I think the lessns t learn fr the new wave, is t d that engagement with the patients befre the service starts (CCG pharmacist) It is nt just srt f saving peples lives, there must be lives that are better (Educatin and training cmmissiner reginal representative) Weaknesses Plicy level weakness There was cncern expressed that the pharmacists had the ptential t be the secnd highest r highest paid individual in a practice. There will need t be discussin abut finding whether better t leave it t individual practices r standardising cntracts. Sme felt that a big weakness was lack f engagement with cmmunity pharmacies in the prcess althugh 60% f the pharmacists were said t have cme frm cmmunity psitins. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 78

80 Others were cncerned that the uptake by practices had been particularly pr in sme areas prbably due t all the cnditins that had t be met. One f the big weaknesses was pharmacists nly wrking very part time I am actually wrking half a day in 5 different practices. Where is yur wn prfessinal cntinuity? By the time yu get in, hw s yur week, that srt f thing, yu have t lg n, reset yur passwrd, set up yur s again n a different cmputer (Pharmacist) I think yu have t be in the practice lng enugh t frm a relatinship because that all just cmes frm trust A if yu d half a day, I mean that wuld take yu a year, mre than a year t gain that cmplete cnfidence. K - I dn t knw where 1 per 30,000 came frm, P - nbdy knws that exactly. (Pharmacist) Let s be realistic 1 t 30,000 is nwhere near as gd as 1 in 15,000. That is a plicy decisin I think we will learn t regret...s there is that trick arund plicy ratis but the fundamental is less patients will get cared fr, less integratin will happen, less utcmes will be delivered in a 1 t 30,000 rati. (Pharmacist) It was said that a lt f practices have actually bypassed ging fr phase tw funding and invested in GP pharmacists withut ging fr the funding because they dn t meet the 30,000 patient criteria. There was sme discussin abut the mney and effrt that went int training GP registrars and that practices gt 6k extra fr a trainer. They wuld like t get mre mney t be able t train their pharmacists. Well I am nt sure it is the lack f talking, it is just it is all abut just sweating the assets basically. If they wanted t put in the funding that GP s training gets, t train pharmacists, they culd decide t d that tmrrw. (Pharmacist) There was als a suggestin that the GMC capability framewrk was adpted by the prject. There was sme discussin abut mre flexibility arund the 1 in 30,000 ging frward as it really depends n the area and the demgraphics may be fine if yunger ppulatin but nt if lts f lder peple. There was a feeling that the evaluatin was almst t early and that the pharmacists were ften yet t be embedded in t the practices and fully trained as IPs etc. Yet phase tw was rlling ut withut the results f the phase ne evaluatin. It wuld take a lng time t see patient utcmes and real result. If yu lk at the evidence based fr example, the effectiveness f medicatin reviews, the interventin f a general practice pharmacist, it is very brad, different peple d different things, s it is very difficult t measure that in a single utcme. Very very difficult t share change in a single utcme in a shrt space f time, yu need a lng perid f time; yu need a range f utcmes t measure therwise (NHS England clinical pharmacist) There was a feeling that sme f the CPPE training and requirements were being develped iteratively and that this was driving the plicy rather than the ther way arund. There was als a feeling that the CPPE training was nt always at the right level especially fr mre experienced pharmacists. IT was seen as a gd thing that it was being made mre flexible t meet individual learning needs in phase tw. Regarding the training pathway cncerns were expressed abut having a prper career pathway fr the pharmacists. The pathway is great except that yu cme ff n the right rad and they get t the end f it, hpefully they are an independent prescriber and they have cmpleted the pathway and registered with the RPS, but they culd ptentially, d nthing fr the next 20 years. S it is thinking abut the next steps isn t it, the whle career structure fr a pharmacist up t an advanced practitiner perhaps r cnsultant level. (Pharmacist) Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 79

81 It was clear that different practices have different needs and that the rle needs t be mre flexible One thing I saw tday which is a little bit f a cnflict that is cming up, a lt f what peple have presented in terms f what they are ding, the fact that the rle is flexible and peple have fitted the rle t suit the practice, cming frm peple ding the rle, and then I suppse the picture f the rle plicy level, is ging this must be patient facing. But actually there is a whle range f things that pharmacist are ding and I just wnder might there be a bit f a mismatch between the bigger picture f what the rle is versus what actually happens? (Pharmacist) Cmmunicatin had nt always been gd and practices did nt always knw what was expected f them. Practice weaknesses There had been a variety f different expectatins as sme GPs had expected the pharmacists t d mre administrative, medicines management duties and thers that the band 7 pharmacists wuld be ready t g int patient facing rles straight away. Unrealistic expectatins n behalf f the practices had been demtivating fr sme f the pharmacists. GP practices expect pharmacists t be able t d mre than they culd, because they emplyed pharmacists at band 7 wh had n experience, but they expected them t be able t prescribe and t be able t d all these things n day ne, which they culdn t. (Pharmacist) Participants had differing views n whether r nt pharmacists wuld deskill ther team members. One f the issues fr the practices is deskilling f ther practitiners. S there are GP s and practice nurses wh are cncerned abut lsing their expertise and medicines in prescribing because the pharmacist takes it all n. (Pharmacy Academic) There is t much wrk t g arund. I dn t think that s a prblem. Deskilling I wuld have thught the pharmacist wuld have been a fcus fr evidence based (NHSE Clinical Pharmacist) Medicine in the practice but wuldn t replace the ther clinicians, but wuld in fact enhance the ther clinicians (CCG representative) Funding was still cnsidered t be a majr issue even thugh there is 50% funding there is still a wrry in practices abut where mney will cme frm t cntinue the scheme after three years. The fact that CCGs had prvided pharmacists free albeit in a mre administrative, rather than patient facing rle, was als cnsidered t be a barrier t nw having t fund them. The lack f trained independent prescribers had slwed dwn the prcess f getting pharmacists int patient facing rles. Hwever, when they d have independent prescribers it was seen t wrk well. There was n additinal mney fr individual practices t train their pharmacists unlike fr nurses and GP trainees. S we have asked ur GP s t take a sessin every 2 mnths t help d cntinual prfessinal develpment with the pharmacists. They said where we are ging t have that time; we are already paying fr the pharmacist. Unlike the GP trainee s, where there is definitely an incentive and a need fr nurses which is definitely an incentive, there isn t ne. I knw mney shuldn t drive but it des. (Training prvider) but there is s much investment and infrastructure ges int making GP registrar s, a gd quality and safe learning envirnment and then GP tutrs are gd enugh t be able t d it. Nne f that has been cnsidered effectively. (Educatin and training cmmissiner) Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 80

82 Anther weakness was cmmunicatin with cmmunity pharmacists they needed t have access t the recrds systems. Patients weaknesses There was a feeling that mre culd be dne t prmte practice pharmacists t patients, as many patients were still reluctant t see pharmacists. It was necessary t g t patient grups, get the receptin staff n bard as they were bking the appintments with the pharmacists. But I think there is a lt mre that can be dne because I think patients are reluctant. It is a health care prfessinal even thugh they have never seen them, it tk s lng fr nurses t get t that pint where patients actually want t g and see a nurse. Often they d, they wuld rather see a nurse than a dctr. (Prfessinal bdy representative) Opprtunities Plicy level pprtunities There was a strng feeling that the scheme had nt been sld t cmmunity pharmacy and that there was huge unrealised ptential. The scheme was seen as a massive pprtunity fr breaking dwn barriers in terms f different sectrs f pharmacy and address all the majr issues arund medicines and transfer f care. I think it is actually linking them, linking cmmunity pharmacists, linking medicine management teams, and linking pharmacists in secndary care t actually wrk as a cllabrative. (Manager f NHS England clinical pharmacists) There was nw an pprtunity t be much mre flexible arund the cmmunity pharmacy cntract. Lcal interpretatin f the cntractual framewrk t allw a bit f flexibility t enhance patient care.s I think in terms f if we are talking abut de-siling and integrating a medicine service yu have gt t have lcal interpretatin f the cntractual framewrk. (Academic) The medicine value prgramme leading t better targeting f medicines was seen as a massive pprtunity. As was the need t cllect gd utcmes measures, I think what has gt t cme is a bit mre bjective data n what has really changed. We have had sme very nice examples there, saw this patient, saw they were n an antiplatelet and an anticagulant and I managed t stp that, and that is abslutely fantastic, that is imprtant t that patient. It shws that peple can make thse interventins, but I suppse at a plicy level, when d we get the data in t shw that, that s public health at that level.., flu vaccinatin rates are up,?plypharmacy rates are dwn There was als an pprtunity t d mre prmtin the participants suggested that minister shuld have been prmting it n day time TV and that peple needed t be made much mre aware f what pharmacists culd d. Participants thught that the pharmacists shuld get mre accreditatin a bit like MRCGP and suggested that the RPS faculty wuld be ideal fr this. This was an pprtunity t recgnise advanced practice as the prfessin has been slw t d this cmpared with ther prfessins. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 81

83 Practice pprtunities Brader wrkfrce Sme GPs saw having a pharmacist pprtunity and had emplyed pharmacists utside f the scheme. Others were mre sceptical f its value Sme f the GP s have cntacted the cmmissiner, t say that with pharmacy and general practice that surely this rle is f mre financial beneficial t the cmmissiner than it is t general practice? This is a patient facing rle s the questin abut hw valuable is yur patient s health fr yu; the reality is hw valuable their time is t them and their business. S that has been really interesting, I have been asked s many times fr a cst impact mdel. If yu put a pharmacist in, hw much d yu get return fr them? We dn t have that s I ask well have yu gt it fr the nurse? N-ne has that, we prbably really shuld, but it is a really tricky. (Educatin and training cmmissiner) Others had grasped the pprtunity S if there are practices that aren t already training GP s r nurses r whatever, and they are bringing in smebdy, a clinical pharmacist that is n this educatin package, prviding supervisin and having the clinical mentring and educatinal supervisrs and s n, I think that in itself creating a learning envirnment within a general practice brings its wn benefits t the practice. (CCG representative) Others saw it as an pprtunity fr cmmunity pharmacy t have better liens f cmmunicatin with GP practices I think cmmunity pharmacists thugh are, I mean they may feel a little bit left behind but they must be appreciative f the fact that they n lnger have t call the GP practice and speak t a randm GP. They nw have hpefully, a designated peer t speak t abut ne f their issues in the cmmunity pharmacy. S it is an extra link but I appreciate they might feel a little bit all the interesting wrk is ging t be dne by this clleague f mine in the GP practice but at least the cmmunicatin, yu knw, pathways are pen. (Educatin and training cmmissiner reginal representative) Patient pprtunities There was an pprtunity t engage with patients befre the next wave starts - ne f the biggest issues patients always highlight in surveys is lack f understanding f medicines s need t build n this S there will be sme segments f the patient practice list which will be very receptive t this, and as we get mre experience, we will knw which nes they are. (Prfessinal bdy representative) I wuld just like t say that it is time fr patients t be educated abut the rles f the different pharmacists. I mean we are all pharmacists and GP s talking abut what we are ding urselves, but it is patients wh need t knw that there is smething new nw fr patients. (Pharmacist) Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 82

84 Threats Plicy level threats There was a perceptin that all the best peple had applied fr the first wave and that the quality f applicants wuld decline ver time sme participants thught that the numbers f applicants were drpping and wndered if it wuld be sustainable. There was a wrry that sme f the cmmunity pharmacists applying fr the secnd wave were nt s clinically aware. Nt all agreed with this thugh and thught different skills wuld be needed depending n the practice. my pint was t challenge the assertin that we have taken the cream f the crp f cmmunity pharmacists, I dn t think that might nt necessarily be the case, we have taken pharmacists with a certain skill level wh have been attracted t a rle with a certain skill level, but it may be that sme areas want mre f thse cmmunity pharmacists skills. (Pharmacist) A majr threat was if GP practices failed t fund their pharmacists at the end f the scheme At the end f the day, the expectatins that GP s will cntinue t emply their pharmacist, that is a threat as well. I think if we dn t deliver then that is a ptential threat. Practice threats A participant was wrried that if we fcussed n clinical skills but failed t acknwledge pharmacists excellent IT and medicines management skills we wuld miss smething. Perhaps we needed bth There was als a wrry abut the csts and the value f the pharmacists: Because actually they questin the value, what is the benefit t them in terms f csts that they are inputting? After thse 3 years, what happens? They have t fund it (CCG pharmacist) Hwever, we have t deal with this threat as ne participant stated I knw we have an issue abut clinical, but I think that is the elephant in the rm. The way I see it, there are different shaped hles k, there is a hspital shaped hle, there is a cmmunity shaped hle and there is a general practice shaped hle. What we are trying t d, we are taking pharmacists and we are trying t fit them int hles that desn t quite fit s there is ging t be sme uncmfrtableness, there is ging t be a hell f a lt f learning, and that bils dwn t the pharmacist. Hw much d they really want the jb and hw much are they prepared t learn? (Training Prvider) Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 83

85 Summary There was wide recgnitin fr the ptential f the scheme in prducing meaningful benefit fr bth patients and prfessinals. There was als recgnitin that this was a significant investment in Pharmacy with bth training infrastructure and finance t supprt rll-ut f the scheme. Cncerns were raised abut the speed f scheme rll ut including a lack f rle definitin. Additinally cncerns were raised abut the cntinuity with existing pharmacy prvisin. Many stakehlders saw significant ptential fr new ways f wrking and the assciated learning, but als expressed hesitatin abut ptential mismatches in expectatin and financial sustainability. NHS England lcal area teams are ptentially a key partner in successful representative bdy liaisn and crdinatin f research and evaluatin lcally. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 84

86 Appendix E - Case studies Case Study Overview This sectin presents case study data frm three sites reprting n site level experiences. They serve as an intrductin t the crss cutting qualitative thematic analysis. They are prepared fr audiences t reflect n similarities and differences acrss sites. A ttal f seven case study sites were identified. Three case study sites were sampled pprtunistically and are presented as individual case studies. Data frm the ther 4 sites, hwever due t time cnstraints at the time f reprting is incmplete and cannt be presented as case studies in their wn right. The views f these participants are hwever incrprated int thse crss cutting thematic analysis. The mdel at Site A is a (relatively) small peratinal site and des nt cver the whle Federatin. The mdel uses 5 pharmacist rles wrking acrss 7 GP practices. The pharmacist rles include 3 CPs and 2 senir CPs (4.56 WTE). The mdel at Site B is a (relatively) small site. The mdel uses 9 pharmacist rles wrking acrss 8 GP practices. The pharmacist rles include 7 CPs and 2 senir CPs (8.6 WTE) The mdel at Site C cvers 3 practice sites and the mdel at this site uses 4 junir CPs and 1 senir CP, alngside the SCP wh has been in pst befre the pilt scheme. The fllwing visuals demnstrate the similarities and differences between the case studies in terms f management structures and peratinalisatin. Figure E-1. Graphical representatin f the rganisatinal structure f Case Study site A Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 85

87 Figure E-2. Graphical representatin f the rganisatinal structure f Case Study Site B Figure E-3. Graphical representatin f the rganisatinal structure f Case Study Site C Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 86

88 Case Study A Backgrund (Site and Staff) Site A is a Federatin f ver 30 GP practices in ne gegraphical area. The rganisatin in a nnprfit limited cmpany and the nly sharehlders are the GP Practices. The federatin rganises a range f services linked t primary care with the aim f patient benefit. These services include practice supprt (such as centralised HR, risk and gvernance sharing, and shared cmmunicatin including crss practice Wi-Fi, intranet and mbile wrking), and patient services (such as dmiciliary phlebtmy). Mst members f staff at the Federatin hld dual rles als wrking within the practices. The Federatin is the rganisatin which applied fr the scheme and hlds the cntract fr the Clinical Pharmacists emplyment. The Federatin site is an individual CIC business entity. The site is unique as it emplys pharmacists directly and invices the GP practices fr the pharmacists time. The mdel at Site A is a (relatively) small peratinal site and des nt cver the whle Federatin. The mdel uses 5 pharmacist rles wrking acrss 7 GP practices. The pharmacist rles include 3 CPs and 2 senir CPs (4.56 WTE). Anna* as well as taking the site lead rle als wrks as a senir CP in Practice A2. Anna als acts as a clinical mentr fr CPPE ffering mentring t ther senir CPs n the natinal scheme. Anna is emplyed directly by the Federatin (as Head f Clinical Pharmacy) and was invlved in the prject since the planning and applicatin stage. Her backgrund is as a pharmacist with experience wrking in hspital and fr the CCG, in a similar rle wrking acrss GP Practices. Adam* is a partner at practice 1, which is a training practice. He is als a Directr f the Federatin. Alice is a senir Clinical Pharmacist wrking 36 hurs ver 4 days acrss 2 GP Practices, 3 days at the first practice and 1 day ( hurs) at the secnd. A site visit was cnducted t practice A1 where Adam, Anna and Alice are based fr mst f their time. It is the largest practice in the site grup. Site A1 has c10000 patients and staff include a management team 9 GPs, 4 nurses (including 1 nurse partner wh is als Lead Primary Care Nurse Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 87

89 fr Alpha* Clinical Cmmissining Grup), 3 HCAS and a wraparund healthcare team. Site A2 small practice with c3000 patients and 3 GPs, 1 practice nurse and 1 HCA. Cnceptualisatin This sectin cvers the cnceptualisatin fr invlvement in the scheme, frm planning and mtivatin thrugh the applicatin prcess, ratis used and any turnver at the site t date. Planning / Applicatin Site A received 5-9 applicatins per pst and the quality f the applicants was cnsidered average. Site A lead felt while centralised recruitment acrss the site wrked well, practice invlvement in the recruitment prcess was really imprtant as team fit needs t be cnsidered and practices were invlved in interviews. Mtivatin The driving factrs fr the prgram fr the practice included Difficulties in primary care recruitment Difficulties in meeting patient demand fr appintments Recgnitin f the benefits that CPs can bring t primary care Recgnitin f the need fr a specialist in medicatins Difficulties in recruiting GPs Ratis The applicatin site has an verall apprximate 72k patient list resulting in a rati f 1:12/15k. The rati fr senir t nn-senir CPs was restricted at a maximum 2:1 t allw mentring and training. Mst CPs cme frm a nn-clinical backgrund and s have significant learning needs. Turnver Within the first year f the scheme ne GP practice left the scheme (due t an inability r unwillingness t cmmit t ffer the mentring required) and ne CP left their pst. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 88

90 Implementatin This sectin relates t the lcal implementatin f the pharmacist rle and cnsiders their inductin, training and mentring. Inductin At site A they had access t an established senir CP, in the Practice Lead rle, wh had wrked previusly bth with practices and with the CCG wh was able t supprt with inductin and training. Anna recgnises that early mentring and supervisin pprtunities with GPs is crucial t integratin f the pharmacist. Practices nt engaging with educatin and training needs f the pharmacist has hindered integratin at this site. Anna suggests that the attitude f the pharmacist is crucial t their integratin and the rle requires a can-d attitude and knwing yur wn limits while being willing t learn and adapt Training Site A reprts that CPPE training is gd but frustratingly shrt ntice. Site A recgnises the need fr lcalised training within the pharmacy cmmunity and has set up a learning cmmunity with pilt pharmacists, ther practice pharmacists and lcal CCG pharmacists. Anna suggests that training fr pilt site leads wuld be useful, t include: Mentrship training Leadership training Perfrmance management Alice suggests that she nw takes respnsibility fr her wn learning, bth with supprt frm Anna and mre autnmusly. I have said I want t knw a little bit mre abut pain management, well here is smene yu can get in cntact with. Like seeing if I can sit in a pain clinic. But then there have been thers I haven t gne t, ding wrk abut HRT, just finding wh the lead is and say can I cme and sit in yur clinic. Mentring Alice is mentred by bth GPs (including Adam when he is available, but ther GPs when he is nt) and the Senir CP/Anna. Alice has a debrief meeting after every clinic as part f her mentring and develpment. Initially the debrief wuld review all cases When I first started it was this is wh I have seen, anything where I thught this needs t be initiated because bviusly I wasn t qualified t d that. S this is my thught prcess, these are the guidelines and evidence that I have based that upn, this is the patient s input n that and this is what I think. Over time the debrief has develped t be pharmacist led and query based Nw it is mre like if I have gt a query r dn t knw where t g frm here r actually I have said the patient need t cme back fr GP input, felt they needed a diagnstic r examinatin assessment, smetimes it is just re-assurance that that is the right thing t d. S that is getting less and less, like tday I just had ne query. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 89

91 Operatinalisatin Activities There is limited awareness amngst patients abut the service. The practice has advertised the rle thrugh psters and n their website but nne f the patients we spke t were aware f this. One patient suggested that a message n the autmated system might reach a wide audience. Several had their appintments ffered t them by receptin but were nt aware it was with a pharmacist. A cuple f peple were referred by the GP and understd they were seeing an expert in medicines. At this site there is sme verall cnfusin abut the difference between a pharmacist in the GP practice, and the ne in the cmmunity pharmacy, even amngst patients wh have experienced bth services. Anna reprts that pharmacists are wrking t lcal targets including fall and frailty reviews and pst discharge reviews fr thse n 8 r mre medicatins. Alice suggests that her wrk varies acrss the 2 practices she wrks at. At the smaller practice site A1 the pharmacists wrk fcuses primarily n audit wrk and writing prtcls. She runs a mrning clinic and sees patients but is nt invlved in tasks and has less patient facing wrk generated frm the practice. I think just because the distributin has been between 3 GP s, they are just used t wrking in their wn way. CP Alice Alice has t be practive at this practice t shw the GPs her capabilities. This has included cntraceptive reviews and targeting QOF measures. Anna supprt this and suggests that the dynamics f the GP practices in terms f appraching change in wrking practices is quite different. She has t be very practive at the ther practice t lead them the way we want them t g whereas this practice is quite frward thinking, as sn as yu mentin smething the change has happened. Smetimes t quick here, yu haven t gt time t think whereas the ther ne is just a bit mre cautius isn t it? Practice A2 is at a time f change with 2 ut f 3 GPs retiring and a new practice nurse being recruited. Alice is ptimistic that her pst can supprt the impending changes and the develpment f new multidisciplinary ways f wrking. Maybe anther GP will embrace it a bit mre and will refer many mre patients my way. And because they haven t really had a practice nurse, they have just recruited smene new s we need t frm new relatinships t see hw we can wrk tgether, t help with the management f the lng term cnditins Alice hpes that her experiences will benefit new appraches in the GP practices I think I am able t share best practice. This is supprted by Anna There are plans aft t wrk mre cllabratively. At Practice A1, Alice wrks fr 3 days a week and reprts that she has a regular daily rutine. Upn arrival she checks bld results, and any paperwrk such as referrals, care hme cntacts, prescriptin requests and medicatin queries. This helps practice 1 meet its target f 24 hur turnarund n any medicatin queries. Alice runs a patient facing mrning clinical frm 9-11 where she cnducts mstly face t face cnsultatins, supprted by sme telephne cnsultatins. Alice spent 30 minutes n face t face cnsultatins when she started this rle, but this has reduced ver the first year t 15 minutes. This time is reduced by half fr telephne cnsultatins. Alice cnducts appintments at patient hmes if they are requested by the patient r the GP but this nly happens frm time t time. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 90

92 Patient appintments can be bked face t face, by telephne but als nline and patients reprted enjying the use f the nline bking system. Sme patients als nw use the nline system fr rdering their repeat prescriptins. Mst patients became aware f the pharmacist in the GP practice when they were invited fr a medicatin appintment and were tld it wuld be with the pharmacist. They were talking abut changing the pill fr me fr bld pressure and they gave me this ne and it was n gd fr me, I had t cme and have a meeting with the pharmacist. S that is hw I knew abut it. Thrughut the mrning as they arise medicatin tasks are distributed t the GPs thrugh the nline system. These tasks include prescriptin queries, nline queries, urgent medical queries, amber drugs, discharge letters, and reviews frm hspital discharges if patients are n mre medicatin. Anna suggests that practice A2 receives arund 100 prescriptin requests per day and arund 10% f these will be urgent fr medicatins abut t run ut imminently. At midday when her mrning clinical ends Alice ges int thse dctrs task pts and wrks thrugh thse tasks, reducing the numbers fr each GP. Alice reprts that GPs appreciate this and ften send messages f thanks thrugh the nline system r the practice WhatsApp grup. On ccasin it is these medicatin tasks which can be very time cnsuming fr the clinician dealing with it. Alice gives an example: A patient in a care hme nw needed t have medicatin cvertly. S we were talking f a repeat template like 15 medicatins, first can they had t be disslved, stability and then it was all arund k d we have cvert administratin frm, the legalities arund it, des the patient have capacity, what are we ding as a practice t fllw that up? Anna reprts that the ther SCP n the scheme spends a significant amunt f her time cnducting patient facing cnsultatins while the junir CPs are taking the prescribing curse and have just started t see patients fr 30 minute appintment slts. The site has ne newly recruited CP wh has replaced smene wh left the rle and as a result their educatin is slightly behind the thers but they are seeing patients. Anna suggests that it is easier fr the junir wh is wrking at the site alngside Alice as she has already develped the preparedness f the site. The evidence shws that at each independent site, and with each GP, it takes time t develp trust in the rle and in the individual in the rle and t establish the bundaries f the rle. As well as the patient facing tasks listed, PL-1 suggests that CPs can use their expertise t cntribute significantly t ther wrk including audit, supprt with CQC requirements, plicy writing and staff educatin arund medicines. Netwrks There is a wide range f netwrking meetings reprted fr the pharmacists which act as shared learning pprtunities. Alice attends regular meetings including the practice meeting that happens at 7.30am n a Friday, and ther meetings ften take place during lunch times. There are weekly lunchtime meetings with prescriptin clerks just t see hw things are wrking, ur prcesses are in place, any specific queries. Anna c-rdinates mnthly peer review meetings fr all the pharmacists at the Federatin s that we have gt a chance t reslve any issues, talk abut any glbal things that we need t d. Directly after their meeting they are jined by CCG pharmacists fr a jint sessins with a clinical fcus. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 91

93 S it might be a CPPE learning at lunch, we have had mental health pharmacists cme ut and d a sessin n hw t switch anti-depressants. We have had HIV pharmacist came t talk abut drug interactins, just t raise awareness. While Site A invests a lt f time int netwrking, the time available is limited and meetings ften take place as wrking lunch meetings as there is n ther time available it is trying t fit everything in the day. Anna is als wrking building netwrks with lcal care hmes. There are 6-7 care hmes lcal t the 2 practices cvered by Alice. Anna visits ne lcal 40 bed care hme mnthly and wrks with the regular nurses there. They als wrk clsely with 2 lcal larger care hmes ( beds) and say this is challenging, nt least f all because f the high rate f turnver f staff in the care sectr ne f the managers I met with, she had nly been in place fr 2 days, and the ther ne had nly been there fr 2-3 mnths. Early meetings affrded the pprtunity fr Alice t supprt the care hme staff supprt them t slve sme f their prcedural issues and sme f the things they face arund rdering, rdering n time, interims, urgent prescriptins. Currently time restraints prhibit clinical wrk in the care hme. Hwever, recgnising the imprtance f develping this area the site are evaluating the pprtunity t participate in the CHIPS study and release sme capacity t have a presence in the care hme. Practice A1 has a cntract with a 37 bed intermediate care hme (patients wh are bviusly nt quite well enugh t g hme, but are well enugh nt t be in hspital) and Alice supprts this wrk. Each SCP has 3 slts per day allcated fr discharge and medicatin reviews with these clients wh require urgent and fast turnarund. Anna als reprts strng links with lcal hspitals. Well frm my perspective, it is arund advice and guidance s I wuld get in cntact with the cnsultant pharmacist within the hspital and wrk with them. It is mainly thrugh medicines infrmatin, I am lking at [clinical system], if there is any queries r issues n discharge, r I feel that there have been changes that have ccurred and nt been quite well cmmunicated, just that transitin when patients are ging back int cmmunity, I think is huge. Anna has acted n behalf f the Federatin in partnership with the CGG t c-rdinate an event t bring tgether pharmacists in the ALPHA area wrking in different rles. It was held at the hspital and funded by the hspital educatin training budget. The aim f the event was t share experiences and gd practice. S there was a table arund what is was like t be a GP pharmacist that I lead, there was anther ne abut what CCG pharmacists d, there was ne abut medicines infrmatin and what it can d fr yu and they rtated arund these different tables t learn mre abut what ges n in hspital, what ges n in primary care, what ges n here s we have gt mre f an understanding abut what the barriers were The event was a success and there are plans t repeat it annually. Anna reprts the imprtance f nline netwrks as a cmmunity. We have a practice pharmacist WhatsApp grup, we have ne fr the federatin where we can ask anything, nthing t d with patient details, then I have gt a bigger ne which includes all f the practice pharmacists in (cunty), hwever they are emplyed. Als there is a few randms frm (ther lcal areas utside the cunty) because I am the clinical mentr fr CPPE. Alice als reprts using an list t cmmunicate with her CPPE grup frm the lcal area. Anna clearly has a large impact n the netwrking aspect f the scheme implementatin. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 92

94 Partly because I am a busybdy and partly because I have wrked at the hspital and I have wrked at the CCG, I have gt really gd netwrks, that helps that I knw peple everywhere. This demnstrates the imprtance f a lcally recgnised, respected and well netwrked leader fr scheme impact. Rle Develpment Anna reprts that less experienced pharmacists start with mre restricted areas such as hypertensin and vitamin D deficiency and expand as their cmpetence and cnfidence grws. Alice wrks acrss 2 cmpletely different practices. Her experiences shw the benefits f the CP rle t grups f practices wrking tgether where they can wrk mre cllabratively tgether, and share gd practice between sites. As practices experiences changes in the wrkfrce and the demand frm patients they can develp new ways f wrking in a MDT t benefit patients, especially thse with lng term cnditins and ther plypharmacy acrss care hmes, mental health and cntraceptive fields. Alice reprts satisfactin in the rle as it prvides a challenge, every day is different, and she is learning. even thugh there is cntinuity in the types f wrk that I am ding, yu are faced with different queries and yu are learning all the time and that is what I am really enjying actually, just learning new things. CP Alice Other Emergent Areas Anna suggests that the scheme has identified a need fr a natinal scheme f access t evidenced based medicatin practical infrmatin fr primary care. The experience f seeking supprt fr the care hme patient n 15 medicatins wh needed t be administered cvertly highlighted t the practice the need fr a centralised infrmatin service. We can ring [area1] if it is a specific query abut a patient under the care f [area1] but fr sme reasn, [area2] hld ur cntract. But we have n access t x which is the bk that wuld tell us abut. S t find ut this infrmatin we have t put phne calls thrugh t meds infrmatin, we culd be ding this quickly urselves. N we haven t gt access t that. SPS, we need Stckley [drug interactin bk] but we haven t gt access t Stckley. Als we can get thrugh the library, it needs srting ut... Anna suggests that Sctland has all f these things cmmissined centrally and natinally and this wuld be a gd example fr England t fllw. Outcmes Capacity Anna and Alice bth A that the biggest benefit f the rle is its impact n primary care capacity and therefre access fr patients t appintments. It is imprving access fr patients, the fact that we are freeing up GP s time, I think that is huge. CP Anna Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 93

95 Site A reprts that the CP rle releases apprximately 1 hur f GP time per day. Patients A: It s a bit like is it ging t free up all ur appintments, are yu ging t be able t get an appintment easier? That wuld be gd because I think that is what we need definitely. Patient AC I think maybe nwadays we rely n pharmacists a lt mre because the dctrs are s busy, the practices are s big, smetimes it is easier t see the pharmacist Patient AC. Patient Fcus Grup, Site A Quality Patients felt they had hlistic and in-depth appintments with the pharmacist. I think treating yu as an individual, nt smebdy that is h high bld pressure r diabetic, actually having the heart t care as well. Patient AR Alice reprts that CPPE have encuraged CPs t cllect patient satisfactin data. Her data shws 100% satisfactin. Alice is able t reprt n examples where she undertaken reviews that might nt have been undertaken previusly but were necessary therefre significantly imprving the quality prcedures in the practices. Alice suggests that her impact n safety is appreciated by the practice team. I think the GP s and the practice manager here really appreciated that because this practice wants t be the best it can, but time and pressures mean things just have t get dne quickly s t have eyes that are prperly lking at things, they really appreciate that, the imprvement in quality that we have achieved. We have dne a lt f wrk arund these amber drugs, they thught they were ding it brilliantly quite understandably, but then actually we fund there were still sme imprvements that culd be made, that have really appreciated all that srt f thing. Anna reprts that flexibility in the rle enables the pharmacist t fllw up patients mre than GPs and prvide mre hlistic and wrap arund care. I think we have gt a little bit f luxury f time t sme extent because we have thse afternns where we are ding admin, if we run ver r we have t d an extra bit f leg wrk fr smebdy, it is nt quite the same as the GP s wh have gt blck after blck after blck. Pressure n them all day lng s I think they want t d what yu did, they haven t gt the capacity t d it. If yu talk t them all they all want t prvide the best care they pssibly can but they are under that much pressure in terms f ridiculus numbers f peple sat waiting t see them, it is really difficult. Uniquity Anna reprts clear differentiatin between the GP and CP rles. GP is seen as the majr cntributr t diagnsis, while CP and Nurse make sme cntributin t diagnsis. Hwever, in ther areas the GP and CP bth make majr cntributins- these areas include determining if new medicatin is needed, selecting the best medicatin, selecting the best regimen. In these areas, the nurse makes a minr r sme cntributin. In sme areas, largely administrative. Hwever, in sme areas the CP is seen as the majr cntributr and the GP makes a smaller cntributin these areas include mnitring adherence, repeat prescriptins and medicatin reviews. Patient A1 had suffered with intractable lng standing neurpathic pain nging ver several years and was n repeat prescriptins fr high dses f pregabalin. He was regularly seen at the GP Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 94

96 practice, was admitted t hspital several times per year and was under the pain clinic. He was referred t the pharmacist fr a medicatin review and she was able t explre his cncerns abut ther medicatins (drwsiness while wrking as frklift peratr). The pharmacist was able t wrk with the patient ver several appintments, and take advice frm hspital pharmacist clleagues t develp an alternative prescribing regime. Her suggestin was ne which had been previusly made by the pain clinic but he had been unwilling t try at that time due t his cncerns. Patient A2 was referred t the pharmacist with a rare cnditin and side effects frm medicatin injectins frm the hspital. The patient revealed during the cnsultatin with the pharmacist that he was feeling depressed and suffering frm night terrrs. He was reluctant t take a prescriptin as he had previusly taken anti-depressants fr the prblem but that it had caused erectile dysfunctin. Over the curse f six appintments the pharmacist was able t reslve his reactins t the hspital medicatin thrugh changing the type and dsage and prescribe smething t eliminate bth night terrrs and erectile dysfunctin prblems. Safety Alice als reprts that imprved safety with medicatins is a significant impact f her wrk further benefits f the rle include imprved prescribing quality which can lead t cst saving. Anna reprts regularly reviewing repeat prescriptins and querying medicatins that thers might reissue withut questin. She admits that prescriptin reviews take lnger fr pharmacists than GPs but that they are mre in-depth and regularly result in deprescribing and cst saving n the verall prescriptin budget. Anna cllect data lcally using a Read cde frmulary s that they can analyse wrk themes dne by pharmacists in practice. Anna suggests that suitable utcmes measures and KPIs fr the scheme wuld include: Number f appintments Number f medicatin reviews Patient satisfactin Practice staff and GP satisfactin Clinical pharmacist satisfactin KPIs Site A reprts frustratins with the NHS England reprting and tracking prcess. We were nt cntacted t prvide this infrmatin. It has taken nearly a year t get the crrect spreadsheet (in the end frm anther pilt site, nt NHSE) and s we are nw trying t retrspectively cmplete which is very time cnsuming Anna c-rdinates the data cllectin fr the Federatin practice sites centrally. Anna suggests that the reprting is very time cnsuming and unlikely t generate gd quality data (due t differences in read cding and reprt writing). Anna suggests that an nline prtal wuld be mre efficient fr reprting and a reminder t submit the reprt each mnth, as well as an acknwledgement f cmpletin, wuld be useful. Anna feels that sites wuld benefit frm feedback and data analysis frm the cuntry as a whle. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 95

97 Case Study B Backgrund (site and staff) Site B is a Federatin f GP practices in ne gegraphical area in the Nrth f the UK. The area is in the 1% f mst deprived areas f the cuntry (deprivatin index) and arund 20% f wrking age peple in the area are receiving sme srt f ut f wrk benefit. It is ne f the least ethnically diverse areas where 97% f peple are White British. Mre than 15% f the wrking age ppulatin have n educatinal qualificatins at all and this year the lcal authrity became the first in the cuntry t cease t ffer A level educatin in the area. The Federatin site was cnstructed specifically fr the purpses f the GP Pharmacist prject. The Federatin activity is managed by a separate independent cmpany. The cmpany is a small cnsultancy which was set up by tw peple wh had been emplyed by the PCT/CCG and saw a need fr management cnsultancy in health t develp General Practice. This cmpany ffers a range f management services in Primary Care including Practice Management and Strategic planning fr ne f the large GP practices invlved in the Federatin. The Federatin applying fr the bid als included University B as a partner n the bid t ensure they culd evaluate their scheme and prve the benefits. The independent evaluatin f the scheme invlved undergraduate students cnducting interviews with practice staff n site. On the advice f the lcal area team, ne third f csts in the applicatin were n-csts designed t cver the csts f managing the scheme using nt fr prfit management cnsultancy. The Federatin was planned between the lead GP and the tw management cnsultants, frm recgnitin f the benefits that CPs can bring t Primary Care. The GP suggests that the CCG invited them t apply fr the scheme based n previus experiences f the practice wrking with pharmacists (in a different scheme where pharmacists were cmmissined thrugh the lcal CCG and emplyed directly by the GP Practice). These lead staff brught anther three partners n bard t supprt the bid. The mdel at Site B is a (relatively) small site. The mdel uses 9 pharmacist rles wrking acrss 8 GP practices. The pharmacist rles include 7 CPs and 2 senir CPs (8.6 WTE). Beverly* as well as taking the site lead rle is als Business Manager fr Practice B1. Her backgrund is as a Primary Care HR specialist with experience wrking in the CCG and ffering management cnsultancy t general practice. She runs her wn cmpany which is cmmissined t prvide management service fr practice B1 which includes supprt fr the pharmacists. The fllwing were interviewed fr the qualitative data cllectin: Barry* is a partner at Practice B1, which is a training practice, and wrks acrss several sites. Barry is specialist diabetes GP and an innvatr in Primary Care practice. He is a lecturer n the CPPE training curses fr CPs. Beverly* as abve. Bb* is a senir CP wh has wrked full time as a senir CP n the scheme fr almst 2 years. Bb spend 20 years in cmmunity pharmacy befre selling his practice when training as a prescriber t take a (cnflict free) rle in general practice. He has been a prescriber since 2009 and wrked as a prescribing pharmacist fr a GHP practice prir t this rle. His rle includes mentring ther CPs as well as his wn patient facing wrk. He als wrks fr NHS England in a pharmacy rle. He wrks as a mentr acrss all the sites in the Federatin as well as wrking at site B in a cnsulting rle fr tw afternns per week. Betty* is a CP wh wrks full time and is mentred by Bb. She wrks acrss ne practice based n tw sites. Betty wrked as a pharmacist fr the practice fr five years befre the pilt. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 96

98 Bernadette* is a CP wh wrks full time and was mentred by Bb, but is nw mentred by a senir nurse. She has been in pst fr 18 mnths and wrks 3 days per week acrss 2 practices Practice B1 is split site sme f the wrk takes place at the lcatin f the site visit, but there is anther larger site and staff may wrk acrss bth sites. Site B1a has c11000 patients and staff include 3 GPs and 2 nurses at its primary site. Site B1b is a large Primary Care Resurce Centre with 8 GPS, 2 nurses, 2 HCAs, 2 phlebtmists and ther management staff, A site visit was cnducted t practice B1 where Beverly, Barry and several f the pharmacists are based fr mst f their time and this site is lcated in a building which used t be a schl and is lcated next t a new build schl. The site is at the end f year 2 f the pilt scheme and is nw lking frward t hw the scheme can be sustainable. Cnceptualisatin This sectin cvers the cnceptualisatin fr invlvement in the scheme, frm planning and mtivatin thrugh the applicatin prcess, ratis used and any turnver at the site t date. Planning / Applicatin The CCG invited applicatins frm lcal sites and Beverly decided t apply based n her previus expertise f wrking in this area, and in partnership with Barry and the Federatin f practices. Beverly wrked with the lcal area team t develp their applicatin. The scheme is run under a lcalised management mdel where all pharmacists becme emplyees f the main medical centre Practice B1. Beverly is cmmissined by practice B1, thrugh her cmpany, as a self-emplyed Business Manager. Beverly s rganisatin (her Business partner) manages finance n the scheme and invices the ther GP practices fr the time f the CPs allcated t them. This is the mst prblematic aspect f the scheme and sme f the practices have nt paid Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 97

99 fr the last mnth f services. In this rle fr Practice B1 Beverly is respnsible fr centralised HR services fr the CPs including managing cntracts, insurance, annual leave, training, plicies and prcedures. S even thugh they are ur staff in ther practices they adhere t hw [Practice B1] wrks. Beverly suggests this mdel wrks well fr ensuring cnsistency in prcedures such as training and mentring fr CPs acrss different sites. The rles were put ut t advert and interviews were cnducted by a panel which included the GP and a lcal academic. Barry admits that he fund the recruitment prcess difficult. I fund it difficult t interview Pharmacist when yu nly have experience f ne yu have... I nly have ur pharmacist and they weren t interviewed they were cmmissined. S I ended up interviewing a grup f peple that I have n idea abut their level f expectatin that I shuld have as an interviewer. I interview Nurses all the time, I interview fr the CCG. I have never interviewed Pharmacists befre Barry reprts that interviewees were wide ranging in ability, thugh ften academically ahead f Nurse interviews. Management is key I persnally dn t think the pilt wuld be anywhere near as successful if yu didn t have strng managers. Barry is very strng clinically and has a lt f respect frm his peers. That s a biggie. Because there was anther practice that bid and was tld t g away and write ne like urs and they might cnsider it. S clinically it s gd. Managerially Barry and I are strng mangers and if it s nt written dwn it s nt in the prcess yu dn t d it. Site Lead Beverly Cmbinatin f clinical and business management is crucial. Beverly cnfirms this apprach fits with the safety culture f the practices in the Federatin Clinician s prtectin is key s fr us it was all abut indemnity, wrking t the jb descriptin and nt utside that. And that is just the way [Practice 1] functins. We are a very safe perfrming practise, that is ne f the mst imprtant things t the partners. Beverly cnfirms that the jb descriptin is a wrking dcument under develpment as the rle changes during each year f the pilt and linked t the training undertaken as well as experience bin the rle. I m ging t have a cnversatin frm 1 st April that we need t review the jb descriptins, the indemnity arund it, what we d with that, what we re lking t d with the Pharmacists nw their CPPE isn t taking up as much time. S we need t lk at what we re ging t d with their training in the next 12 mnths. There were sme tensins between the riginal dictate that advertised psts must be permanent, and the fact that the funding was nly fr 3 years; NHS team advised that lcal sites shuld manage this risk. Beverly s site rejected this and ffered 3 year fixed term psts t mitigate the risk f redundancies (and assciated csts) and t mtivate incming staff t take a sustainable apprach t their wrk. Beverly is already in talks with all GP sites at 24 mnths t discuss sustainability f psts thrugh lcal direct emplyment mdels. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 98

100 Liability / Indemnity Beverley suggests that the centralised HR apprach als ensures cnsistency in bundaries and respnsibilities. Beverly suggests that this apprach has mitigated issues in indemnifying CPs which have caused issues fr ther sites. We are very cnsistent in what is expected f thse emplyees within the pilt. There s a jb descriptin and that s all they re indemnified against. S if yu chse t ask them t d smething that s nt in that jb descriptin they are nt indemnified and we will nt take the risk fr that. And yu d be amazed, as sn as yu say that - peple stick t jb descriptins. Because indemnity was the biggest prblem that everybdy else had in the pilt. We didn t have that at all because they re ur emplyees s we indemnified them all. Site Lead Beverley Barry cnfirms that indemnity was nt a prblem fr the scheme, nt least f all because f an existing relatinship with an insurer fr a pharmacist wrking in the practice and negtiatins were underway at the planning stage t avid prblems. N because we thught abut that first s we had all that srted befre bidding. We knew after they were ging t indemnify us, s fund ut what the prescriptins wuld be befre the bid went in. S I wanted that srted befre, because we culdn t indemnify peple but we had an advantage as we already had indemnity with a Pharmacist already. It was a transfer ver t nw we re ging t emply 7 ver and the jb descriptins are ging t change. It was mre that discussin. It did change frm the MDU grup scheme fr the practice cause the MDU wuldn t tuch it first f all. They are nw taken it back. Beverly will be able t tell yu mre as she did the negtiatins. But basically we were n the phne and we said this what we need, this is what is cming and if yu dn t adapt t yurselves t manage what we want then smebdy else will and yu will miss a massive earning n indemnity GP Barry Mtivatin The driving factrs fr invlvement in the scheme was an nging cmmitment t, and recgnitin f, the benefits that CPs can bring t Primary Care. The lead GP / practice had previusly emplyed a pharmacist directly. The lead GP recgnises the value bth that the pharmacist can add t the primary care mix, and the value that primary care can add t the pharmacy prfessin. Lng term I thught Pharmacists culd have a really imprtant rle in patient management always and that what we we re ding in [ur area]. The prblem abut that fr us here the demand in wrk f ur acute prescriptins, discharges and hspital letters, that s a full time jb in its self. I als thught that was quite a rubbish jb [fr], Pharmacists [s it s imprtant that is nt all they d]. That als meant yu didn t get the best f them as a team member. I m abslutely cmpletely devted t a multi discipline team in primary health care and I ttally think that Pharmacist have a huge rle t play. GP Barry Barry suggests that ther sites became invlved either fr recruitment r develpment reasns. There are tw practices that did it because f staffing issues. All the ther practices are training practices and they were srt f sld n that. They knew what they were ding already and they were...hld n a minute we can see that GP Barry Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 99

101 Ratis The rati fr senir t nn-senir CPs was designed t allw fr 1 sessin f pharmacist time per week per whle time equivalent. The list size fr site B1 is 11,000 patients but it is unclear what the full patient list size is fr this federatin site and therefre difficult t cmment n the full federatin level pharmacist: patient rati. There is sme negative feedback frm participants abut the rati. I dn t see hw much f an impact yu can have r it really wrk n that number f patients. T d it prperly and t d it well. Betty CP Turnver Within the first year f the scheme ne CP left their pst. Beverly feels that the site were ffered little supprt, in terms f time r funding by the lcal area team after the planning stage and peratinalisatin became lcalised. Because f lcal plitics we weren t perhaps being supprted as well as we culd have been s we were very much n ur wn. Site Lead Beverly The site has had turnver f bth pharmacists and sites. We ve lst peple thrughut the pilt and practices have nt wanted t cme back n bard Site Lead Beverly Beverly believes that a mismatch in expectatin caused ne f the sites t pull ut. At the beginning f the pilt a lt f peple wh said they had buy in, changed their minds. One f the pharmacists was ffered a rle in anther GP practice nt n the natinal scheme earning 10k mre than the natinal scheme was ffering. This rle had n supprt r training and a fixed limited rle ffering little chance f develpment but the persn mved due t the attractive salary being ffered. She had cmpleted up t December s she was 18 mnths in t the pilt s she d had mst f it and she was gd. One f ur better Pharmacists. She was very gd. Very practive. And my nly cncern wuld be the practice she s gne t she wn t be as well utilised as she was in the pilt but that s her chice. Site Lead Beverly Implementatin This sectin relates t the lcal implementatin f the pharmacist rle and cnsiders their inductin, training and mentring. Inductin There are sme initial set up csts in patient facing wrk that Beverly had nt planned fr. We have a lt mre csts because we have Pharmacists that see patients s we ve had t rder bld pressure machines, stethscpes, since we ve gne nline with the pilt we ve emplyed an extra 6 staff, that s arund 2.7 full time equivalents but the additinal wrk that the Pharmacists create, the patient demand. S while yu wuld say that s a benefit because Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 100

102 the patient is getting service, they re all hidden csts that peple dn t think abut. Our phne cst have prbably gne thrugh the rf. We ve had t buy them mbile phnes because they re ut s its lne wrking stuff. Sharps bxes have gne up because they g ut with sharps bxes These are useful lessns t learn t prvide guidance t future schemes. Training Beverly feels that the amunt f training required ff site including CPPE and prescriber training takes the pharmacist away frm wrking in the practice. There are 18 days f ff-site CPPE training fr pharmacists in the first year, which is a high cst relative t the rle. Furthermre, due a lack f availability f lcal training many pharmacists have had t travel significant distances and n ccasin stay in htels t access training. There is n additinal financial supprt fr this and therefre that cst has t be brne by the practices, as the emplying sites. Beverly gives the example f tw CPs n the scheme wh had t attend a curse in Lndn (despite being lcated in the Nrth f the cuntry) and nly being given 3 days ntice this cst the practices 700. On anther ccasin all 5 pharmacists had t attend training in Newcastle. This is because f a lack f lcally available training in sme areas. S althugh training is funded, it is nt at n-cst t practices, it is a hidden cst. Beverly expresses sme frustratin with training that she suggests was nt ffered but had t be sught and which are ften mre cstly than cnvenient. Betty feels sme f CPPE training was helpful Sme are really gd, excellent, sme f the hands n stuff, the respiratry, cardivascular, the hands n CP Betty But nt all. Because there was n needs assessment fr the training, it was unifrmly delivered t all CPs regardless f experience. There were peple with lads f years and years and years f mre experience than I have. We were all ding the same thing as peple that have never wrked in a GP practice befre. CP Betty GP Barry feels that Pharmacists, and ther primary care health prfessinals, shuld be wrking twards a set f natinal cmpetencies and is wrking natinally t lead the agenda n this. Bernadette reprts that the CPs are auditing their rle t prvide up t date evidence-based training fr their receptin and admin staff abut the pharmacist rle and apprpriate tasks and triaging. They are ding an audit actually this week but that is mre abut stuff cming t us that shuldn t be cming t us. We have gt t flag thse nes and make a list f them. I think it is mainly because they need better training in receptin fr where they shuld be sent t. CP Bernadette Mentring Mentring is ffered t the senir by the GP. Mentring f the junirs is dne by the senir/s. Pharmacist mentring uses same mdel f reduced scafflding t build cnfidence. It tk 6 mnths fr junirs t achieve autnmy in patient facing wrk. Depending n the skills f the individual between 2-6 mnths. Rund abut 6 mnths I wuld say I managed t extract myself. As they gt better, their wrklad has increased because the practice is giving them mre wrk because they can d it much quicker. SCP Bb Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 101

103 GPs had a mismatch in expectatins which impacted n mentring. Yu just make assumptins f what peple can d that they are used t seeing patients and that s smething they wuld have dne n their undergraduate curse. My first mistake was when I called a meeting a year last January my jaw drpped.i realised because I had a lt t d when I train, s I understand the educatinal prcess. The cliff edge f tuching a patient. GP Barry As a result f this the GP designed an in-huse training curse, f very basic patient care, led by Nurse Clleagues. She s actually a Nurse by backgrund and she s been instrumental really in helping plan with the nursing team and training peple hw t d bld pressure and taking weights. Has a plan f hw the rle develps thrugh basic practice and cnfidence building int specialising in the third year. Operatinalisatin The Day Jb / Activities Bb wrks in cnsultatins at site B1 fr tw afternns per week and spends the rest f his time mentring. He runs clinics including lng term cnditins (LTC), respiratry and a pain clinic n Wednesday afternns. Bb has a laptp with access t bth the CCG and the practice (via EMIS). He finds this useful bth fr remte cnsulting but als fr remte mentring, as he travels acrss sites mentring thers fr a significant prprtin f his time. mst f them were initially were chatic s all the practices nw, all the pharmacists nw have gt specific, their sessins are very specific s they d certain things in certain sessins, sme f them are face t face. I agreed with the practice hw many minutes they shuld have fr each appintment r each interactin shuld be, s it if was smething, just a quick review, it is 5 r 6 r 10 minute based n the skill set I have at that practice. Then face t face culd be anything frm 10 minutes t even 30 minutes. SCP Bb, The senir rle als prvides useful cntinuatin t the scheme. S smetimes if they have had a day ff r hliday and there wrk has piled up, s I will help them t clear sme f their wrklad when I g fr half a day. Bb s clinical wrk fcuses n specific areas. He fcuses n piate management in pain clinics. Betty wrks full time at ne practice (acrss tw practice sites) 1.5 days per week are spent n anticagulatin clinics with 0.5 f this time spent n hme visits. Fr the ther 3.5 days per week Betty wrks n a range f medicatin tasks in the practice. S we can be ding tasks, managing acute requests, patient queries, pharmacy queries, GP queries, anything there that relates t medicatin. S usually that invlves sme phne calls. Then face t face medicatin reviews, patients just cme in if they have gt a query abut smething t d with their medicatin. We d lng term cnditin management, anybdy with COPD, asthma, chrnic kidney disease, hypertensin, AF, crnary heart disease, rheumatid arthritis, Betty is allwed, and might spend, up t half an hur n a cmprehensive LTC review. Yes we wuld be expected t d all the base line ps, bld pressures, pulses, heights and weights, then d a bit f diet, lifestyle. We wuld then d specific cnditin management, s Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 102

104 inhaler techniques, things like that if they are COPD, asthma. Just review their symptms, hw they are getting n, and then medicatin review n tp f that. Bernadette wrks fr three days per week; she spends tw days per week at ne practice in a largely patient facing rle and the ther day is spent at a smaller practice in a mre medicines management fcused rle. Arund a quarter t half f Bernadette s time is in managing LTCs. Her patient facing tasks are similar t Betty. I am nly here 2 days and at the mment usually ne f thse mrnings r smetimes a mrning and afternn I end up ding CDM reviews, patients with lng term medical cnditins. Ding a review f their cnditin but als ding a medicatin review at the same time. There is quite a few tasks here like peple are rdering stuff n the acutes that just making sure they can have it again, any queries abut it. Prcessing the medicine recnciliatin n discharge Betty wuld cnduct hme visits n an ad-hc basis as required by the patient. At this site the pharmacists are all trained t d B12s. Bernadette: Then this year we have been invlved in the vaccinatins, primarily the flu vaccinatin. Yes and then that has led n t being able t d the B12 s, shingles, pneumnia, meningitis, s we can d all f thse as well s they can be sltted in t ur day. Betty Then we have been ding the immunisatins, quite a lt f that, the hepatitis vaccines and als ding the B12 s. Beverly checked this with NHSE lcal area team and their respnse was. D what yu want, they re yur emplyees, as lng as they re trained yu take the risk This seemed t be a gd use f an existing appintment slt, then evlved int a regular duty accrding t (seasnal) demand. Betty explains If yu are nly seeing smebdy fr a medicatin review and yu d the flu jab, we wuld bviusly ask them at the same time. That was initially why we gt invlved with it. S I have seen patients fr an INR check but culdn t give them their flu jab at the same time. S it made sense, when they were in getting ne thing dne, they didn t then have t g and see smebdy else. That is where it evlved frm really. But we did have specific flu clinics. Betty CP Discharge management is a crucial aspect f the pharmacist rle. We have what is called a dc-man sessin, at the end f every pharmacists sessin, we have a dc-man sessin. They g thrugh discharge letters and they get shared ut. SCP Bb All the dcuments are scanned n every day in the practice, ur dctr has gt a dcument sessin s they have gt either a mrning r an afternn t d the clinic letters. They have gt allcated time t d the changes if they can d them, it just depends n hw many they have I think. But we always get the discharges. S they lk at them first and then they cme t us. CP Betty Yes s the GP s review all the dcuments and letters s anything that cmes frm an utside surce, then they will be distributed t us. We get thse n a daily basis. They can be anything frm clinic letters, s when they have had a change f medicatin, r smebdy Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 103

105 needs t start new medicatin, Vitamin D s we tend t get. It culd be things like appliance requests, r discharge, we get all thse. CP Bernadette Bb, senir CP behaving autnmusly at 18 mnths in the pilt, decided t fcus his wrk n pain management as he nticed the need arising frm the way the practice management repeat prescriptins f pain medicatin. I have been ding them ff my wn back but we haven t actually been calling them pain clinics. I have been having sessins, I have been picking up all the nes I see prly managed and peple are just giving them mre and mre mrphine, nw and again they request cme acrss my desk because ne f the ther things I d is urgent requests, prescriptins fr repeat, this practice fr example, fr whatever reasn, they dn t put up any f their pain relief medicatin n the repeat. This is a gd example f wrk driven by the needs f bth the patients and practice, but als by the natinal agenda. Clleagues / Relatinships There is a tight netwrk between the pharmacists. We have all gt quite clse actually. I just tend t speak t the guys here. Betty CP They stick tgether in training and have created their wn lcal cmmunity. Like there is a few f us here in this practice, because there is a few f us in the pilt, ur little pilt wuld stick tgether. Betty CP Beverly has experienced tensins between pharmacists due t verlap in respnsibilities. She feels strngly that management shuld be prvided frm bth business and clinical and nt slely clinical. My view n hw it shuld have been managed was that Senir Clinical Pharmacist n. 1 shuld be respnsible fr that Senir Clinical Pharmacist n. 2 shuld be accuntable fr that. They are managed by the Clinical Lead because they are clinical. That didn t wrk. All management I believe in the pilt shuld g t a manager nt a clinical. Because clinicians are nt managers. I think that wuld be ne area where I wuld say we failed massively in the pilt. Netwrks The lead GP ffers a tutrial that the CPs crss-federatin can cme t nce a mnth. These centre n specific areas, such as hypertensin, and are case based. Other meetings include: We have mental health d case reviews, we have safe-guarding meetings with wider disciplinary, health visitrs, everyne cmes. Everyne can write up their stuff, it s all fantastic learning and learning tgether And then everyne learns. They prbably haven t been this invlved, they are nw getting much mre invlved. We have a nice guy wh speaks every mnth as well Cmmunity Pharmacy Bernadette spends a lt f time dealing with prescriptin queries frm cmmunity pharmacy Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 104

106 I think mst f the queries I have are frm cmmunity pharmacy, they cme thrugh us s I am in cntact with quite a lt f the cmmunity pharmacies. It is prbably, nearly every day really. I can speak t smene n a Friday 3 times a day. Relatinships with cmmunity pharmacy are imprtant. Bb gives an example: They can pick the phne up fr me, I can pick the phne up fr them, they never refuse if I make any changes. Fr example, I always have a gd cnversatin with the pharmacist s they understand what we are ding s they expect it. Smetimes I might d them in batches s I explain t them. Fr example there is a patient in [a nearby area], ne f the ther practices I see, and wh was n daily prescriptins because f his chatic life. Every mrning, they gt a call frm the patient, they had t arrange fr a prescriptin, send it electrnically t the pharmacy etc. and it was very labur intensive fr the practice. It was very awkward fr the pharmacy and it was very bad fr the patient because the patient had t g there, he had t ring, he had t hang arund, yu didn t want this type f character hanging arund all day. S what I did I arranged fr repeat dispensing, made a deal with the patient, made a deal with the cmmunity pharmacy, went and trained the cmmunity pharmacy staff hw t manage this patient, rganised daily frm Mnday t Thursday and a 3 day prescriptin n a Friday, then batches f 3 weeks at a time. S the patient wuld get a quick review, 5 minutes. Hspital pharmacy Bb is wrking n a scheme fr the NHS linking clsely t hspital pharmacists. I have a very gd relatinship with hspital pharmacists. As my ther rle as [NHS rle], I literally, every pharmacist in [lcal area] knws me. I have n difficulty accessing chief pharmacist r any f the pharmacists in the lcal hspitals, I knw them all. At the mment I am implementing thrugh my rle at NHS England, I am ding electrnic transfer f care t cmmunity pharmacy s all the hspitals and hspital pharmacists n discharge, send a cpy f the discharge t cmmunity pharmacies. There are sme administrative difficulties with wrking clsely with hspitals and results but the pharmacist can still cntribute t imprving GP capacity. Bb gives an example where he can make a referral fr testes but he can t get the result until he has dne an imaging curse, besides which he isn t in every day, s he gets a GP t authrise the referral, secretary t make and the results cme back t the GP. This saves the GP a lt f time as it is the referral letter which is the time cnsuming part f the prcess. CCG The site wrks clsely with the CCG medicines management team n safety issues. I have actually just dne a big piece f wrk fr the CCG, we had 24 searches t run n high risk medicines. S we went thrugh all f thse, patients n ACEs with n renal functins, patients n ACE and an ARB, patients n fluxetine and clpidgrel and interactins, antipsychtics, meds that increased QT s, we have dne quite a big piece f wrk recently. But that all frms part f wrking with the meds management team at the CCG s we wrk with them. Rle Develpment Barry sees the rle develping like the nurse t be an advanced practitiner in primary care. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 105

107 That s when I put in the bid. That yu wuld have Pharmacists that wuld be light advanced practitiners in a similar mdel t Nurses. Nurse Patients, Nurse Practitiners, The whle range, frm assistant practitiners, health care assistants. The whle range f staff ges thrugh and be trained thrugh here. Changes in Primary Care Practice Practice B1 plans t divide its planned and acute care management. A nurse is emplyed as a Planned Care Manager and wrks clsely with the pharmacists wh are slwly develping specialisms t enable them t manage much f the planned care. This is thrugh fr example pain management, diabetes care as well as ther LTCs. Betty wrks clsely with the planned care team. I suppse it depends n the issue and what the query is. We wrk bviusly very clsely with the nursing team because we are part f the, it is nt really a nursing team as such, it is a planned, s the chrnic disease reviews and things, cme under planned care team. We fall under that umbrella s that includes the phlebtmists, the nurses and the pharmacists and health care assistants; we all wrk tgether as a team. It depends n the issue as t wh it wuld g t, I will speak t everybdy. CP Betty Barry cnsiders the rle vital t the skill mix and as a result is cnsidering replacing a Nurse rle with a pharmacist We have ne full time pharmacist but we re nt ging t emply anther Nurse s we will have 2 Pharmacists We re nt ging t replace a Nurse. We have t recgnise that practice Nursing is a challenge and actually it s a cnscius decisin that we need a different skill set Patient R nw sees the pharmacist every 6 weeks t review his bld pressure and medicatin. This is saving GP time in care fr LTC. Patient L, and several thers at site B, wuld rather see a Pharmacist cnsistently than a range f unfamiliar GPs I wuld rather g t him Patient L, Site B Outcmes Capacity Patients are aware that times are changing and the system is n lnger as it nce was. If yu culd get the same dctr and I think everyne wuld say the same, and they knew my whle family, brthers, mum, dad and everything, but this day and age yu are nt ging t get it are yu? Patient R, Site B At Site B Patient R apprached the practice fr an appintment and an appintment was available with a CP befre a GP and he was happy t accept this. I have had n prblem; it was easier which is brilliant. Access is imprved fr peple with LTCs but thrugh the pharmacists there is als wider access t flu jabs. Yes bk it in if we have time. I think that is why we have dne that because everybdy shuld be able t d it, there is n reasn why we can t d it, and if we are here and we have gt time, just d it. Yu have gt the patient standing there; it is easier fr the patient isn t it? They can cme up t the receptin and they can get t see smebdy. CP Betty Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 106

108 At Site B patients cmpare the service, very favurably, cmpared with GP appintments as they air frustratins with incnsistency f GPs (seeing different nes, getting different advice) and f limited appintment lengths as a result f the increased pressure n primary care services. Patients reflected n the psitive experience f lnger appintments tailred t need. They als suggested that while appintment length is imprtant, s is the apprach. Patient P She explained abut my warfarin, my blds up and dwn, and I am here basically every frtnight. She takes an interest in yu; she treats yu like a persn I knw they haven t gt the time, yu are basically getting dictated t by the GP, yu d this, yu d that, and everything will be fine. Whereas the pharmacist, they say it differently. Smetimes yu can t wait t get ut f GP surgery. Whereas the pharmacist yu can sit there and yu feel at ease. Patient R Exactly the same Patient L I was excited t see him the 2 nd time because I felt that gd. Patient Fcus Grup Discussin, Site B The SCP is aware that the CP apprach cmbined with lnger appintments benefits the patient experience. I think the thing is with me peple talk t me because I ask them abut themselves. I have had a few f the receptin peple saying t me that wman has just said hw wnderful yu are. But it has been mre because I have sat and listened t her talk abut her diet and things like that. SCP Bb CPs are aware that they are imprving capacity fr the GPs while benefitting patients with LTCs. I suppse it has enabled them t get n tp f all thse peple with the chrnic diseases, a lt f them weren t cming, it has given them a lt mre clinic time fr them t be seen, I think we deal with queries that nrmally ther surgeries, the dctrs deal with them. I have nt wrked in any ther surgeries but it is hard t see hw GP s culd functin withut a pharmacist nw because we deal with stuff that wuld take them time t d. They culd be seeing patients s it is gd fr them, and me. CP Bernadette Bernadette includes mental health as a chrnic disease and reprts hw pharmacists can prvide the fllw up fr these patients, saving time fr GPs in this area t. S peple wh have started n anti-depressants and need a review with the GP, after 4 weeks. The receptin put it n my list but they have gt t be dne by a GP. We can d the 6 and 12 mnth reviews but nt thse nes CP Bernadette Quality Betty is allwed, and might spend, up t half an hur n a cmprehensive LTC review. Yes we wuld be expected t d all the base line ps, bld pressures, pulses, heights and weights, then d a bit f diet, lifestyle. We wuld then d specific cnditin management, s inhaler techniques, things like that if they are COPD, asthma. Just review their symptms, hw they are getting n, then medicatin review n tp f that. CP Betty Bernadette t and lnger if necessary and feels this has benefits fr hlistic care. Yes we d have lnger appintments f 30 minutes, I think that lady, I was with her fr abut an hur. I was waiting fr sme results as I needed smething s I was messaging peple but Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 107

109 while I was ding that I was talking t her. The things that I am prbably picking up that need ding that might make a difference is like peple wh shuld be n alendrnic acid. There is quite a few that I pick up that I refer fr DEXAs. I dn t knw if that has made a difference t anybdy but ne that I was speaking t, she seemed, I said I am ging t d this because yur FRAC scre is a bit high, we shuld give yu DEXA scan. And she said I have been having all these aches and pains I think that is what I need. Whether r nt it was but? CP Bernadette At site B the pharmacist cnducted a medicatin review at hme fr patient R wh struggles with mbility and had recently suffered a heart attack. Especially when he came t the huse, he was there fr a gd half an hur. He explained everything. S it was mainly the warfarin, what it is, what it des, and the ther ne was aspirin. There was ther tablets and he said that is because f that. I asked, because I never suffered with bld pressure, but when I had the heart attack they put me n them and he explained why. I said I had never suffered with that but he said but nw yu have gt t have them. Because I asked he explained why, because yu have gt t be lwer than a nrmal persn nw. Patient R, Site B At site B, Patient L als reprts n a hlistic appintment which led t his better understanding f his cnditins and medicatins. I thught he was a dctr t tell yu the truth but the ne thing I will say, he had gt the time. He tld me all abut the medicatin I was n and the side effects that they were giving me. When yu are with the dctr, yu see that many different dctrs, yu are in and they want yu ut straight away. He saw me fr minutes and discussed all the medicatin, why it was given, why it must be dne, and he was saying the medicatin I was n s he tk me ff that and put me n smething else. Patient L, Site B Patient PN agrees that the lnger appintments lead t enhanced medicatin understanding and increased self-care. They spend time t explain things t yu and basically, us as patients that is what we need. If yu are n a lt f medicatin, yu want t understand what yur medicatin is ding t yu, any side effects, things like this. They are an abslute asset here. Patient Pn, Site B Patient P agrees and suggests that an appintment with the pharmacist was the first time his use f asthma medicatin had been reviewed and that supprt and advice led t imprved medicines ptimisatin. I have been n salbutaml since I was a kid and I have nly just had the spacer. I used t take it in my bag and just take it, I felt it was easier. But he taught me t use it withut the spacer and he was telling me hw I shuld feel in my chest as I am taking it. The dctr, he desn t necessarily explain hw I will feel when I am taking that. He shwed me hw lng t hld it fr until it feels right. Then he tld me t start breathing ut srt f thing, yes. Everything that he said was right, and I dn t need t use it as ften as I had been. At site B the CP fixed a series f nging lng term prblems fr patient L and cntributed t the imprvement f his lng term cnditin and verall health thrugh self-care. My diabetes was a bit, he explained t me abut that, my diet and stuff like that, that s hw I packed up smking, I will take my hat ff t him. The s called prfessrs and dctrs that I have been under and it was like saying the lights nt wrking, the first thing yu wuld d is check the bulb wuldn t yu? He just said what are yu symptms and I tld him. He said that lks like it is a bit t in deep? Yu have had tests fr everything else, hepatitis, HIV, it was just smething like that s cmmn and I have been 3 years n 8 tramadl a day with pain in my legs and jints. But then he was mre cncerned abut me being addicted t the tablets Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 108

110 then. I have gt t try and get yu ff them nw because I have been n them 3 years, srt f like a junkie nw. Patient L, Site B Patients discussed hw the CPs had given them lifestyle advice and helped them t imprve their diet, exercise and t stp smking. He is lking at the picture, yes. He said t me that was causing the diabetes because the tablets that I was ne was making me tired, s then I was taking energy drinks s it was a vicius circle. He said that needs t be packed in, just drink water, we have gt t try and get yu ff thse tablets. Patient R, Site B Patient L suggest that he is nt usually receptive t advice but fllwed specific CP help and advice t cntrl his diet. Several patients discussed smking and said that they felt judged by a GP and guilty fr smking, especially with chest related cnditins, but that mtivatinal interviewing by the CP enabled them t stp smking r start wrking twards this. Uniquity Betty suggests that hlistic care and use f unique skills in medicatin lead t safer Primary care. It is patient safety, patient care prbably. Just the fact that we can ffer that time t patients t lk at medicatins, that maybe the GP s dn t really have time t d. CP Betty SCP Bb agrees that safety is significant area where pharmacists imprve primary care and this shuld be an evaluatin measure t evidence the benefits f the rle. T sme degree medicine safety incidences, if anybdy culd measure the number f medicine safety incidences r prescribing errrs, in GP practices befre the pilt, befre and after the pharmacist, is there any change? SCP Bb Betty suggests that she it is likely her actins have prevented emergency hspital readmissins thugh planned care, but feels that this wuld be difficult t evidence She came in t see me fr hypertensin and med review, her pulse was really ff, she was tachycardic, it was 140, clammy, sweaty.. I did her pulse twice because I thught I will leave it and check it again at the end and even the dctr, when she checked it, it felt like it was a regular pulse but then it wuld miss s it was really dd but it was racing. We sent her in and she gt diagnsed then with AF and she was treated fr that. CP Betty SCP Bb gives examples f actively imprving safety in the discharge prcess. GP Barry believes that nw pharmacists handle all discharges this reduces errr therefre imprving safety, service and efficiency. S every single discharge ges thrugh a pharmacist. It s already been t the nurse s if they need t fllw up that admissin it s dne. We wuldn t have dne that befre; we wuld have just checked the drugs made sure that they were wrng, cause we made s many mistakes it was untrue, created mre wrk GP Barry The future Site B is in its secnd year and wrking twards a sustainable future fr the pharmacists wrking acrss the Federatin. Sites reprt t Beverly that they think the psts are expensive and ptentially nt value fr mney. The invice csts fr a pharmacist include an n cst fr senir pharmacist mentring time. Practices als reprt being unhappy at paying fr time when a pharmacist is training, especially as this is such a significant amunt f time away frm practice within the first tw years f Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 109

111 the scheme, and this is nt relative t the pst (i.e. a 0.1 WTE and 1.0 FTE have the same verall training csts). They are wrking twards a future lwer cst mdel than the pilt as training and mentring will be significantly reduced. The way we are selling it t them is it wn t be as high as they are currently because within thse csts there are 30% n-cst. What we ve dne at [Site B2] with [CP Brian] is we ve negtiated yu can have him at that cst but yu will have n senir cver. Because if yu re ging t have him fr an additinal day, he desn t need the senir cver at year 2 f the pilt hwever the cver that we will prvide in the n-csts are the training, the mentring and everything like that. S ur wrk in this next financial year is t cnvince the practices this is a viable ptin. This is what yu ve paid t date and this is why yu ve paid this. Hwever, this is what yur cts are ging t be nce yu ve emplyed them. The nly thing with that is Pharmacists are nt cheap. GP Barry Barry fully expects all pharmacists frm the scheme t be emplyed directly by their practices after the pilt. He suggests that they have becme embedded and this is particularly evident when they are absent frm their day jb fr annual leave r training. *Bb wasn t here ver Christmas and everybdy was falling apart. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 110

112 Case Study C Backgrund (site and staff) Site C is a Federatin f GP practices acrss ne suthern area f the UK. The federatin cvers 3 practice sites and the mdel at this site uses 4 junir CPs and 1 senir CP, alngside the SCP wh has been in pst befre the pilt scheme. Practice C1 is a small practice. Christine is the practice manager at site C1 and the Federatin lead fr the scheme. Charles is the senir Clinical Pharmacist at site C1 and has a dual rle wrking fr NHS England. Charles is 5 years pst qualifying and has experience in cmmunity pharmacy. He wrked as a GP pharmacist befre the scheme. Chle is the CP at site C1. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 111