Clinical Pharmacists in General Practice: Pilot scheme

Transcription

1 Clinical Pharmacists in General Practice: Pilt scheme Independent Evaluatin Reprt: Executive Summary 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... 3 Intrductin... 4 Overview... 4 Scheme utline... 4 Methds... 5 Summary findings & discussin... 7 Impact... 7 Impact n General Practice... 7 Impact n pharmacists... 9 Impact n patients... 9 Impact summary Recmmendatins Cmmunicatins and managing expectatins NHS England cmmunicatins Managing expectatins Internal cmmunicatin Recmmendatins Sustainability and future mdels Sustainability Mdels f peratin Recmmendatins Lng term develpment and training Lng term develpment Training Recmmendatins Summary f recmmendatins Cnclusin References Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 2

3 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) 3

4 Intrductin Overview This executive summary presents a digest f ur research. The full reprt includes a deeper verview f the 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. Recmmendatins are prvided at the end f each sectin and summarised at the end f the reprt. The bjectives f this evaluatin are 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 Scheme utline The General Practice Frward View (GPFV, NHS England, 2016) utlined the measures that 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) 4

5 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, additinal training was sub cntracted t several partners including Red Whale, HEIs, OSCA (Caching fr Health), NICE. 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 The diagram presented in figure 1 summarises the research methds used and data cllected which infrmed this evaluatin. These include a literature review, SWOT analysis with external stakehlders, analysis f natinally cllected rutine service data, quantitative data frm a survey f scheme participants and qualitative data frm in-depth interviews with scheme participants. The mixed methds apprach taken t this evaluatin research allws specific fcusing and testing f hypthesis whilst als allwing fr examinatin f the breadth and depth f a phenmena t learn mre abut them. This is crucial t facilitate a wide ranging research infrmed evaluatin which can bth map bth what has happened but als develp understanding f hw the scheme is experienced by the key participants healthcare staff, patients and the wider healthcare cmmunity. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 5

6 Figure 1. Summary f the evaluatin methdlgy and number f data cllected Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 6

7 Summary findings & discussin The full reprt cntains a wide range f data cllected thrughut the evaluatin. The key findings frm this data are summarised here under fur key headings: Impact f the rle Cmmunicatins and managing expectatins Sustainability and future mdels Lng term develpment and training Impact Data presented shws the imprtant impact that the Clinical Pharmacists in General Practice pilt scheme has had n a General Practice, Pharmacists and patients. Three full case studies are presented (Appendix E) which psitin this data within its lcal cntext and gives an insight int the day t day wrking and impact at a site level. The fllwing summary utlines the key impact f the scheme n General Practice (including GPs), n Pharmacists, and n patients. Impact n General Practice The rle has had a wide ranging impact n the wrk in General Practice, mst ntably n cntributing t imprved capacity and changes in wrklad, and in medicines ptimisatin and safety. Capacity and wrklad There is evidence that the CP rle cntributes t an increase in the capacity f General Practice t see patients, at a time when demand is high and recruitment f GPs is difficult. Data frm the survey shwed imprved capacity was cited as the main benefit f the scheme by pharmacists and site leads. Data frm SWOT analysis shwed this as a perceived strength f the scheme, by a wide range f external stakehlders, at a practice and patient level. This is reinfrced by qualitative data. There is evidence that the capacity released by the CP rle benefits the General Practitiner. 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. Survey data frm CPs shws that a significant prprtin f CP time is usually spent cnducting medicatin reviews, servicing prescriptin requests and queries and managing discharge. This is underpinned by qualitative data, fr example at site E, CPs acrss all federatin sites wrk n a centrally crdinated discharge management prcess. Rutine service data (Appendix B) shws that these tasks, which wuld usually be cnducted by the GP, allw their wrklad t becme mre fcused. At Case Study site B there is evidence f the CP rle cntributing t a cmplete change in their wrklad management between acute and lng-term care, with the majrity f lng-term care prvided by nurses and pharmacists, allwing GPs t manage acute care. (Appendices E & F) The CP is seen as a valuable expert additin t the Multi-Disciplinary Team (MDT) with a range f clleagues suggesting that they learn frm the CPs and their unique set f skills (Appendix F). Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 7

8 Findings frm the qualitative and rutine service data als demnstrates that the CPs cntribute t imprvements in medicines management and care f lng-term cnditins which can lead t increased achievement f targets at multiple levels (Natinal, lcal, practice). Medicines ptimisatin and safety There is evidence f the CP rle cntributing t medicines ptimisatin in a variety f ways. This has cst saving and safety implicatins and can help t increase achievement f natinal, lcal and practice level targets. Fr example there is evidence f CPs implementing previusly unimplemented NICE guidelines fr prescribing fr particular lng term cnditins, CPs carrying ut CCG led prescribing prjects and cnducting lcal federatin r practice level audits. These strategic appraches are supplemented by day t day examples f medicines ptimisatins directly with patients thrugh medicines and lng term cnditins reviews. 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 Interview, Site B Data shws that the CP rle cntributes t increased safety in general practice. This is highlighted thrughut the findings. In the natinal survey data, pharmacists, practice site leads, GPs and ther clleagues all cited safety as ne f the majr benefits f the CP rle. (Appendix C). All CPs interviewed fr the research believed that imprved medicatin safety is a significant impact f their wrk. Betty (CP Site B) believes there is an ptimisatin and r safety interventin in 70% f her cases. Alice (CP Site A) 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. Site B wrks clsely with the CCG medicines management team n safety issues. CP Interview, Site A 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. CP Interview, Site B Medicatin safety is summarised briefly here but explred mre fully in the detailed analysis f qualitative data in appendix F. The data briefly highlights sme f the key areas f impact f the CP rle n General Practice. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 8

9 Impact n pharmacists Data frm the natinal survey f CPs shw that thse undertaking the rle enjy high levels f satisfactin. 89% agree r strngly agree that they enjy wrking in their rle, 89% agree r strngly agree that they wrk autnmusly in their rle, 87% agree r strngly agree that they wrk clsely with thers in the practice and 89% agree r strngly agree that they are accepted by ther prfessinals in the practice. This is underpinned by qualitative data. Pharmacists in the new CP rle reprt that they enjy the pprtunity t wrk clinically, and in a MDT, utilising their specialist skills in medicines. The CP rle allws fr the utilisatin f existing skills and netwrks. In qualitative data (Appendix F) CPs reprt that the jb is challenging which makes it rewarding, and that it affrds the pprtunity t utilise existing skills whilst als develping new nes. 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 Interview, Site A Our findings als demnstrate ways that CPs utilise their existing knwledge f, and netwrks in, ther areas f pharmacy (such as cmmunity r hspital) t enhance the CP rle and benefit the wider prfessin (Appendix F). Impact n patients The impact n patients is explred in great detail thrughut the case studies (Appendix E) and qualitative data (Appendix F). Patients reprt the benefits f increased access t a healthcare practitiner and the tailred appintment lengths ffered by the CP. Data shws that CPs ffered variable appintment lengths t patients accrding t their time in pst and t patient needs. Patient interviews shwed that they appreciated these lnger appintments that ffered the pprtunity fr an in-depth high quality review. Several patients reprted 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. Patients cmpared the service, very favurably with GP appintments as they air frustratins with incnsistency f GPs (seeing different nes, getting different advice) and f limited appintment lengths. Patients reflected n the psitive experience f lnger appintments tailred t need. Patients reprted that persnalised appintment lengths led t hlistic care. I think it is a gd idea I mean I have nly seen [Chle] the nce but she spent a lt f time with me, I was in there fr 20 minutes. I was impressed with that. I have never had that level f service in this surgery. Patient Interview, Site C She explained things and spent time with me. It was at least 20 minutes; she went thrugh everything with me and made sure everything was alright with me. Very infrmative. Patient Interview, Site A Patients reprt a clear understanding f the benefits f a specialist in medicatins in the Primary Care team. Patients reprt gd advice abut their medicatins frm the CP which leads t better adherence and minimises side effects. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 9

10 It has been explained t me because we weren t actually tld what they d, hw they wrk, when t take them. The dctr desn t tell yu that. Patient Interview, Site C There are several examples f impact n patient utcmes in case studies and patient stries. At site B patient BPn understd their medicines in a way they never have, Patient BL has imprved his diabetes and verall health, and Patient BP had his asthma medicatin reviewed fr the first time in his life which led t imprvements in his cnditin. An additinal benefit f the CP rle is the increased healthy lifestyle advice and mnitring affrded t patients, ften thrugh the use f mtivatinal interviewing skills. I am diabetic and I had t g t [Chle] and I am n 500mg metfrmin a day. She put it n a sheet and I had t write everything dwn like what I ate in 2 weeks. S when I went back t her there were these big red circles (laughing) yu shuldn t be eating that. I have tk ntice f it and tried t cut dwn a bit (laughing). She said yu will be surprised hw much sugar is in them. When she explained it t me, because I thught cereal bars they seem healthy, she said n. (laughing) I thught I was being gd but bviusly nt, they have gt mre sugar in than if yu just have the cereals. Patient CJF They are always reminding me abut smking Patient CAW I have cut dwn t a day nw! Patient CL Patient Interview, Site C Several patients reprt increased quality f life and self-care as an utcme f their interactin with the CP. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 10

11 Impact summary Althugh ur 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 lng term cnditins (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 Quality and Outcmes Framewrk (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) 11

12 Recmmendatins The impacts bserved n multiple levels are recmmended as further areas fr investigatin and measurement. Our qualitative findings can be quantified thrugh further detailed evaluatin studies. The fllwing recmmendatins build n examples f gd practice data cllectin bserved at site level. Measures f 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 I run ff a reprt n a mnthly basis fr all the pharmacists, it tells us hw many medicatin requests they have actined, whether they are acute r repeat nes, hw many bld tests they have rdered, hw many bld tests they have interpreted, hw many patients they have seen face t face, hw many phne reviews they have dne, hw many level 1 2 r 3 med reviews they have dne, just t give me an idea. Because that is actually telling the practice, that is t actually shw the practices wh we want t get n bard, lk this is the wrk pharmacists d Site Lead Interview, Site A Requires cmparative data abut the functins and impact n ther rles Example data f pharmacist vs GP activity at Appendix A Wh was ding the med review befre D yu replace appintments that culd have been ffered by a dctr because it s mre cst effective t have a Pharmacist there? If yu think abut all clinical med reviews went t a dctr in ur practice. Nt ne f them wuld g t anyne else because the GP wuld be the persn respnsible. S having a Pharmacist there seeing 40 patients a day fr clinical med reviews, extraplate that ver 5 days Medicines ptimisatin Senir Clinical Pharmacist Interview, Site C 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. 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? GP Interview, Site B 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. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 12

13 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 I think the true magic is sme f the qualitative stuff that has actually been dne. I wuldn t have knwn abut this hmeless prject, we have gt ne pharmacist nw sat ding acute triaging ver at ne f the university campuses, we have gt anther clinical pharmacist wh has nw taken n the vice chair f the PCPA [Primary Care Pharmacists Assciatin], cmmittee representatin. We have gt 3 representatins n central England care hme develpment plicy, ne is the NHS lead with the PCPA n the new care hme cmmittee grup that they are lking at develping with regard t specifically care hme wrk. I think all f that unspken, r unrecgnised wrk that has actually happened, that desn t get captured with the way that we are currently using thse NHS KPI s. Measurements f impact n pharmacists Site Lead Interview, Site E 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) 13

14 Cmmunicatins and managing expectatins NHS England cmmunicatins Gd cmmunicatin by NHS England at bth CCG level and directly t sites can facilitate clear understanding f the rle. Cmmunicatin was identified as a weakness in the SWOT analysis at a plicy level. Tp dwn cmmunicatin had nt always been effective and sme pilt practices did nt always understand what was expected f them. Cnsistent cmmunicatin and supprt fr lcal area teams, and practice site leads is a recmmendatin and further research shuld include these as significant stakehlders in the scheme. 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 pharmacists 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, SWOT analysis fcus grup interview Stakehlders reprt that they benefit frm sharing gd practice between sites, acrss sites, acrss areas, and natinally. There were 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. Onging cmmunicatin shuld cntinue with a wide range f stakehlders including cmmunity pharmacy, pharmacy and medical prfessinal leadership bdies, patient grups, academics, and training prviders. Managing expectatins The research identified a small number f mismatches in expectatin which were a barrier t the scheme s implementatin. Gd cmmunicatin with stakehlders is imprtant t take these expectatins int accunt and explre assumptins and t infrm them f examples f practice. Expectatins largely relate t the scpe f the CP rle and the speed f scheme integratin. The rutine service data captured (Appendix B) suggests that at an early stage in the scheme a significant number f medicines reviews are still being cnducted by GPs, which is cunter t the expectatin that pharmacists will cnduct many f them. A variety f different expectatins were reprted and sme GPs had expected the pharmacists t d administrative, medicines management duties and ther prescribing task and that the band 7 pharmacists wuld be ready t g int patient facing cnsultatins 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, SWOT analysis fcus grup interview The research identified sme mismatch in GP expectatins abut what pharmacists will be ready, willing and able t d safely at the start f the rle and are trained t d n their undergraduate curse in terms f patient cntact. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 14

15 Sme GPs shwed a lack f full understanding f the csts f the scheme, r had unrealistic expectatins abut the time t realise the benefits f the scheme, and expected a quicker return n investment than is pssible. There was ften a mismatch in GPs expectatin f the CP and the scheme and therefre made (smetimes unrealistic) assumptins abut CP capability. GPs need guidance t be invlved in CP recruitment. 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 GP Interview, Site B Expectatins and assumptins abut pharmacists knwledge f primary care can be detrimental t prviding the supprt and training required. GPs that 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. Frmal guidance fr GPs n inductin and mentring culd supprt the implementatin f future iteratins f the scheme. There is evidence f sme mismatch in expectatin f respnsibilities sites between the lcal area team, the federatin and the individual sites including the SCP rle. 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. Survey data, Appendix C Wrking clsely at and acrss these levels facilitated clear guidelines n respnsibilities related t the CP rle. All site leads interviewed expressed sme level f frustratin at a discnnect between the external training ffered t CPs and the requirements f their day ne and nging day t day practice as defined by the site. It might be useful fr external training prviders t cnduct sme cmmunicatin wrk with site leads in rder fr them t better understand the training which the pharmacist will undertake and hw it can cntribute t their rle develpment. Several sites reprt variance in GP expectatin, within and between practices. Many sites reprt that the first year is significant t build trust and awareness between GPs and Clinical Pharmacists abut the bundaries and develpment f the rle. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 15

16 Internal cmmunicatin Practice site leads suggest that gd quality lcal level cmmunicatin can aid integratin 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 Survey data, Appendix C At Site A cmmunicatin is centralised at a multiple practice level. GP Harry feels that integratin f the CP and cmmunicatin f their capabilities is vital t the success f the scheme I think if yu are ging t make this prject successful, r t imprve the success, I think it is understanding what their rle culd be and it is getting a cmmunicatin strategy that means that everybdy sees everybdy else. She is ne f these peple wh has actually becme part f the team bth [inside and] utside wrk s when they g ut fr a meal r drink, she is included and smetimes drives that GP Interview, Site H Mst sites have sme kind f federatin netwrk fr clleagues which is ften supprted by a virtual WhatsApp grup fr ff-site cmmunicatin. There is evidence f ff-site cmmunities f practice being develped in assciatin with the natinally cmmissined area based learning sets fr CPs. There was evidence f the benefits f the CP rle being maximised where strng netwrks and internal cmmunicatin exist. These are explred in detail in appendix F. They demnstrate that the rle has wider benefits thrugh links with hspital pharmacists, cmmunity pharmacists and wider pharmacists and allied health prfessinals. 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, SWOT analysis Fcus grup interview Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 16

17 Recmmendatins Manage and enhance effective tw way cmmunicatin Maintain clear lines f tw way cmmunicatin between NHS England t CCG 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 Manage expectatins f all stakehlders thrugh clear guidelines and cmmunicatin Manage GP expectatins f the CP 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 CP rle (i.e. clear guidance n Senir CP mentring, GP mentring, Practice Site Lead and Lcal Areas team supprt) Manage 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 Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 17

18 Sustainability and future mdels Sustainability Sustainability is explred in detail in the full reprt in the Literature Review and Findings, Case Studies (Appendix E) and Qualitative Data (Appendix F) and summarised briefly here. Sustainability f the CP rle has been bserved t be achieved by a large number f CPs wh are nw integrated, valued and held in high esteem by the practice sites and GPs they wrk with. We see we can t survive withut pharmacists, they are part f what we d. GP Interview, Site A The message I wuld give is where the pharmacist des prperly becme part f the practice, then there are virtually n negatives in terms f the rle. S nce yu get ver that hurdle f really getting the pharmacists wrking in the practice as part f the team then it wrks. It is just getting ver that first hurdle Site lead Interview, Site D Practice site leads suggests that CPs need t begin t wrk autnmusly frm external supprt in rder t be sustainable. Site leads suggest that in rder fr their rle t be sustainable (at 36 mnths) CPs shuld be wrking fully autnmusly patient facing by 24 mnths. It is suggested that this shuld be achieved by the third year f the scheme in rder fr the scheme t be perceived as sustainable at a site level and wrthy f lcalised funding. I think what we are quite cnscientius f at the mment is if it has been quite heavily supprted. We have been making the decisin as the federatin as we are ging int the 3 rd year; they have really gt t be self-sufficient. They have gt t have sme internal peer resilience, the federatin can t cntinue t supprt them in that rle, withut that degree f sending, there has been a cnscientius decisin t say this week we will g int that t srt f say, take the ft ff the gas a little bit Site lead Interview, Site E The site lead and Senir CP rles have less sustainability built int the rle and as such may nt sustain beynd the scheme. Research int ecnmic viability and full return n investment (ROI) calculatins wuld be useful fr sites t infrm decisins abut rle sustainability. Mdels f peratin A range f successful mdels f peratin were bserved and are reprted t infrm future iteratins f the scheme. Survey site data shws the huge variance in site sizes and peratinal mdels (appendix C). Detailed case study data including visual representatins and detailed breakdwn f different mdels f peratin are ffered at Appendix E. Successful elements f bserved mdels included the fllwing: Buy in f sites frm early in the prcess Site leads played a crucial rle in gaining site level supprt. Survey data frm site leads suggested 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. Quantitative data shwed that several GPs Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 18

19 were invlved in interviewing fr the CP pst. Sme sites were strategic in their apprach t site level buy-in facilitated by federatin level supprt. When we were lking at putting the bid tgether, what we did was a little bit f wrk. We put the practice managers and their leads t becme partners tgether as part f the GP federatin t actually d a little bit facilitated planning tgether t lk at anticipated retirement, maternity cvers, really just a crss mdel exercise t get an early buy in fr an pprtunity fr them t cnsider a clinical pharmacist. Clear cmmunicatin between and acrss sites within a federatin Site Lead Interview, Site E Data shwed sme sites where cmmunicatin had nt always been gd and practices did nt always knw what was expected f them. By cntrast at sites with clear cmmunicatin, in particular arund the CP rle bundaries, this helped t facilitate clear realistic expectatins. 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 survey data Strng lcal supprt fr CPs and GPs frm a practice site lead at federatin level Survey Data The tw previus examples are facilitated by the practice site lead and demnstrate sme ways that the rle helps t facilitate the integratin f the CP supprting bth CPs and GPs t understand and wrk with the new rle. Data shws that the site lead als helps t facilitate administratin f the rle, ften including human resurces and finance issues. They als play a key rle in rganising and supprting training and mentring fr the CP pst. The pilt site lead is ften key in recgnising the rle f research t shw the benefits f the rle and cllects and disseminates lcal level data. 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. Strng lcal supprt fr CPs frm a GP mentr and Senir CP utilising a reduced scafflding methd f mentring A perid f inductin fr the CP is imprtant fr integratin and generating a sense f belnging these are shwn t suffer where an inductin perid is nt ffered. I can't stress enugh hw imprtant it is fr the CP/Senir CP t be part f the practice team frm the utset. Integratin is key Survey data Mentring mdels are nt universal. Mentring can be ffered by GPs, Senir CPs r site leads, r advanced nurses, r any cmbinatins f these. Best practice mentring mdels include where a range f supprt is ffered by multiple staff. A reduced scafflding apprach t mentring, utilised fr GP registrar training, is successful in building cnfidence. Scaling tasks accrding t ability and cnfidence is imprtant. Several CPs reprted in the survey pen cmments that the best training they had in the rle was their GP mentring. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 19

20 Survey and qualitative data shws that GPs have limited time available fr mentring, and are nt ffered a payment fr mentring CPs in the same way as they are with GP registrars. Data shws that mentring is practive and intensive in the first six mnths in pst (r until CP prescriber status is achieved) then reduces t reactive and supprtive fr the fllwing eighteen mnths. Several sites indicate reducing mentring s that the CP pst is self-sustaining by the end f secnd year in pst, A clear jb descriptin and bundaries fr the CP rle Gd cmmunicatin t sites abut the bundaries f the CP rle help t facilitate clear and realistic expectatins abut the CP rle. The jb descriptin fr the CP can help t facilitate this, and it can be a fixed dcument r ne pen t develpment alngside the rle. One site suggested that they fund the reslutin t indemnity issues thrugh a welldefined jb descriptin with clear bundaries. 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. Site Lead Interview, Site B At ne site the jb descriptin is a wrking dcument under develpment annually as the rle develps during each year f the pilt and this is linked t the training undertaken as well as experience in the rle. A clear management supprt structure and HR functin fr the CP rle The CP rle requires a perid f intensive supprt n implementatin with a reducing level f supprt ver time. A lcally supprtive structure is beneficial A lt f supprt has been necessary frm all members f the primary care team, including GP time Survey data At several sites the human resurce (HR) functin fr all CPs is centralised at the federatin level. Site lead B suggests that this centralised HR apprach ensures cnsistency in bundaries and respnsibilities and has mitigated issues in indemnifying CPs. Pharmacists embedded within practices fr mre than three days per week Survey data shws that the mst ppular mdels shw that majrity f CPs are wrking 4-5 days ver 1-2 sites (althugh this is within a scale f huge variance). Site lead Fred gives an example f a CP wrking 1 day per week in a practice and the practice becming frustrated that the scheme was nt generating pace fast enugh until the wrking hurs were increased until 2 days per week There is evidence that the rle shuld be a minimum f tw days per week, and ideally three r mre, at each site in rder fr the CP t be embedded in lcal practices and prvide cnsistent patient service. 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. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 20

21 Clear tracking f CP rle impact by CPs, Senir CPs and Practice Site Leads Lcalised research f benefits facilitates the nging sustainability f the rle and the scheme. Sharing gd practice in lcalised research appraches facilitates learning acrss sites. Several sites gave examples f lcally cllected data, at site r federatin level, and the way they had been able t utilise this data. Just befre the pilt bid had launched, we did an internal clinical srt f template that all the clinical pharmacists used t recrd any f the interventins and I think that was very key t us and an early pprtunity Site Lead Interview, Site E Site C expects CPs t be emplyed directly at the end f the scheme but appreciates that research and cst will be vital t sustainability. At site C the SCP (wrking 0.2 FTE) is able t cite basic natinal key perfrmance indicatrs statistics abut his mnthly activities. This mnth I have seen nearly 900 patients and ut f thse 900 patients, 700 were clinical medicatin reviews, 150 were lng term cnditins, 50 were medicatin reviews, medicine queries, medicine recnciliatin, and hme visits maybe. Senir Clinical Pharmacist Interview, Site C Recmmendatins Further evaluatin wrk shuld evaluate the sustainability f the pst beynd the initial 3 year funded perid as a measure f scheme success Cst effectiveness analysis f CP Return n investment culd usefully supprt rle sustainability Future perfrmance mnitring f sites shuld include data abut the mdels emplyed in sites; Successful wrking mdels shuld be identified and shared as examples f gd practice. Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 21

22 Lng term develpment and training A range f successful mdels f peratin were bserved and these can usefully infrm the lng term develpment f the scheme and the rle. It is acknwledged that in sme respects the pilt scheme was rganised and managed with sme key differences t later waves and as such, relevant changes are likely t already be in develpment. Lng term develpment Data als suggests that cmpetency and assessment f cmpetency fr the CP rle shuld be develped at a natinal level t supprt establishment f the rle, and t aid the develpment f interprfessinal trust. The survey highlights that many CPs were mtivated t apply fr the new rle t cntribute t develpment f the prfessin. The CP rle cntributes t a change in the pharmacy wrkfrce. The significant numbers invlved in the verall rllut f the Clinical Pharmacist in General Practice Pilt is supplemented by a large number f anecdtally reprted similar patient facing rles which exist and are nt part f the pilt scheme. This significant shift in the numbers f pharmacists required t fulfil these rles requires further research and evaluatin. The lng-term impact f the rle shuld be investigated t determine the impact n undergraduate pharmacy training and placements. GPs in this study suggest that undergraduate educatin (including pharmacy pre-registratin pprtunities) need t change based n the develping rle fr pharmacists in primary care. Significant investment will be required t stabilise this new third career pathway (alngside hspital and cmmunity) fr pharmacy training. Strng cnsideratin shuld be given t supprting the develpment and funding f undergraduate curricula t take int accunt the changing prfessinal rle f the pharmacist. This includes greater in-curse n-site clinical patient cntact and the way independent prescribing is taught as an ptinal pstgraduate prgramme. Furthermre mbility between sectrs shuld be explred and encuraged facilitating the develpment f gd quality transferable skills fr the pharmacy prfessin. Training CP 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 WTE 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 backfill cst t practices. The cmmissined training supprts the needs f the early innvatr pharmacists but a lng-term mdel f develpment shuld be cnsidered in relatin t the needs f clinical pharmacists in general practice. Recmmendatins Natinal cmpetencies fr the CP 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 Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 22

23 and ther allied health staff) as well as representative bdies (RPS) 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 CP rle as the third majr career chice fr pharmacists alngside hspital and cmmunity practice including due cnsideratin f remuneratin 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 Natinal Evaluatin f Clinical Pharmacists in GP Practices (Pilt Phase) 23

24 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 cmpetencies fr the clinical pharmacist rle shuld be develped t aid 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) 24

25 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) 25