Clinical Pharmacists in General Practice March 2018 1. Background Following a successful national pilot programme, the General Practice Forward View committed over 100million to support an extra 1,500 clinical pharmacists to work in general practice by 2020/21. This is part of a wider expansion of the general practice workforce so that patients have better local access to a range of highly trained health professionals for their needs. Pressures on primary care are increasing with GPs dealing with an increasing number of patients with chronic medical conditions and an ageing population with complex medical and social needs that require longer appointments. General Practice is currently facing a crisis with increasing workload, workforce recruitment and retention difficulties and poor morale with high levels of stress in the current workforce. There is a workforce crisis in general practice with difficulties in attracting doctors to GP training and a shortage of qualified GPs and retention of trained GPs. As the number of GPs is unlikely to increase dramatically there is a requirement to look at how primary care can deliver quality services differently whilst making the most of its resources. Hillingdon CCG and the Hillingdon Primary Care Confederation worked together to prepare a bid for Phase 2 NHS England funding and the Primary Care Board approved the proposal to provide match funding for a model of 3 Clinical Pharmacists in May 2017. The approval was for a three year CCG financial commitment of 348,000 for the 3 posts, with a 2017-18 (or Year One) commitment of 81,000 and an application was submitted in June 2017 via the NHSE portal, to be considered by NHSE in the next tranche of applications in September 2017. Subsequently, informal feedback from NHSE pharmacy advisers suggested that NHS England would not support a proposal for less than the ten clinical pharmacists modelled in the NHSE guidance for the population size of the borough, which resulted in the application being withdrawn. Following the success of the work undertaken in general practice by the CCG Medicines Management Team, it was decided to bid for Phase 4 of the NHS England funding. Due to the tight submission dates, the bid was submitted January 2018 following approval in principle from the CCG Primary Care Board and the Confederation has subsequently been informed that it has been successful in its bid. Therefore, this paper is formally seeking approval for match funding for a three year period at the total cost of 990,000 over three years. 1
2. Service Model There is great potential for clinical pharmacists working within the community setting alongside existing and new services and service providers, to help deliver pharmaceutical care to patients with complex medical conditions and thereby avoid unnecessary A&E attendances, emergency admissions and readmissions to hospital. The successful bid that was put forward to NHS England, is for 10 WTE Clinical Pharmacists 2 of whom will be senior and assist with strategy and supervision. This team will work across the borough supporting primary care. This was based on the NHS England guidance and General Practice Forward View which refers to 1 WTE clinical pharmacist per 30,000 of the population. They will be assigned to all confederation practices and work closely with the CCG pharmacists and team and the confederation board. Supervision and mentorship will be at practice and locality level with overall supervision from the confederation Lead working closely with the CCG pharmacy team. Clinical pharmacists will work in general practice as part of a multi-disciplinary team in a patient facing role to clinically assess and treat patients using their expert knowledge of medicines for specific disease areas. They will be prescribers, or training to become prescribers, and will work with and alongside the general practice team. They will take responsibility for the care management of patients with chronic diseases and undertake clinical medication reviews to proactively manage people with complex polypharmacy, especially for the elderly, people in care homes and those with multiple co-morbidities. Clinical pharmacists will provide leadership on person centred medicines optimisation (including ensuring prescribers in the practice conserve antibiotics in line with local antimicrobial stewardship guidance) and quality improvement while contributing to the quality and outcomes framework and enhanced services. Clinical pharmacists will have a leadership role in supporting further integration of general practice with the wider healthcare teams (including community and hospital pharmacy) to help improve patient outcomes, ensure better access to healthcare and help manage general practice workload. The role has the potential to significantly improve quality of care and patient safety. The Clinical Pharmacists will provide direct clinical input to patients and medication reviews. This will lead to the potential to avoid hospital admission and releasing GP time to focus on more complex conditions. 3 CLINICAL PRORITY AREAS Long Term Conditions Nursing, Residential and Care Homes Polypharmacy The focus within these priorities areas will include medicines optimisation, liaison with stakeholders responsible for patient care, contributing to care planning and development of high quality pharmaceutical care for patients. Page 2 of 8
Our Service Model will be delivered by the locality based clinical pharmacists supported by their senior pharmacists and the management team. Key roles Clinical pharmacists will be supporting patients and carers where appropriate to review treatment in line with best practice and guidelines to best manage their conditions. They will be reviewing potential for rationalisation, addressing any concerns regarding side effects, concerns, compliance and to ensure robust and ongoing monitoring going forward. Working therefore to better manage long term conditions and at the same time educate and support patients and carers to have better knowledge regarding their medication and conditions They will facilitate joined up prescription advice for patients with multiple long term conditions, working with clinical colleagues to address the challenges and priorities of the most complex patients, for example managing patients with Congestive Heart Failure with Chronic Kidney Disease. Additionally, ensuring patients have assessment and advice for the best mode of delivery of their medication according to the clinical status. Also referring patients for MUR s and NMS service to the local community pharmacists where appropriate. Working with key stake holders to advise step down prescribing, in line with routine and advanced care planning. E.g. working with Care Connection Tams, Care Homes Teams and End of Life Support. Our model would include the routine referral to the clinical pharmacists at the time of advanced care planning decisions. Working alongside practices and ACP partners to manage discharge medication changes following admissions. Providing support and advice to practice prescribing teams Increasing capacity in primary care to focus on deployment of clinical expertise on appropriate patient care through delegating work to the clinical pharmacist to better manage prescribing in the clinical focus areas. To provide prescribing reviews of patents who are prescribed polypharmacy, assisting to reduce Iatrogenic morbidity and unplanned urgent care therefore. To provide prescribing reviews to patients who are frequent attenders in practices, UCC and A& E departments. Thereby reviewing causes and prescribing issues to address. Thereby working to further reduce unplanned care and A&E attendances. They will be working as independent prescribers as an IPP non-medical prescriber. Moreover our team will work with local community pharmacists and referring patients to them from the practices / community for assessment, advice and treatment where appropriate. The Hillingdon Primary Care Confederation will work with local partners to implement the Clinical Pharmacists on a locality basis further fostering primary care collaboration and feeding into the existing clinical services accordingly. North Hillingdon has a higher elderly population whereas the community in Hayes and Harlington is more young families but a more deprived part of Hillingdon. Pharmacists will be deployed across Hillingdon deploying expertise in according to appropriate need in an Page 3 of 8
equitable manner. We will work with Health Education England to ensure we have the appropriate skill set to ensure pharmacist are trained to address appropriate needs. The successful pharmacists will undertake a 3 year educational programme with Health Education England which includes enhanced skills and knowledge and enables the clinicians to obtain their independence prescribing status. Currently 16 Hillingdon practices are supported by part time pharmacists. The focus of the existing practice based pharmacists are varied, however they are all practice focused and not embedded within the integrated approach and patient facing model outlined in this paper. The Confederation and CCG programme will engage these pharmacists and practices and work to ensure an integrated approach over time. However, the 10 Clinical Pharmacists included within this model are additional and will be deployed to support patients across all practices, ensuring equity for practices and patient access. Benefits to the patients Supporting patients to get the best use of their medicines and identifying medicines related issues Independent prescribing qualification for pharmacists which will improve timely access to medicines for patients, deliver care closer to home, reduce general practice workload, enable self-care and self-management of conditions, improve patient safety and improve treatment results of conditions and improve treatment results for patients by maximising the benefits of clinical pharmacists. Benefits to general practice Expanding the general practice team to include clinical pharmacists, with their skills and knowledge. This will allow reallocation of general practice workload. Increase GP practice capacity to see and help more patients Ensure safer prescribing and improvement in patient safety and quality of care. Increase capacity to offer more on the day appointments Improved integration with the community and hospital pharmacy teams. Benefits to the wider healthcare system Improvement in the clinical and cost effective use of medicines Better integration with the wider healthcare systems/teams due to the clinical pharmacist being a key point of contact for primary and secondary care services Optimisation of the patient journey through the healthcare system. 3. Objectives and KPIs 1. Reduction in medicines wastage by thorough scrutiny of prescriptions requested, ensuring medication is synchronised, reconciliated where appropriate, and stopped if not required by the patient 2. Improvement in number of medication reviews/change in behaviour for patients with long term conditions (better self-care) this will be via medication reviews with the IPP, with emphasis on adherence to treatment plans, whilst ensuring that the relevant monitoring is taking place. IPPs will focus on medication review clinics in their areas of clinical competency. Page 4 of 8
3. Improved patient access to GP and wider workforce/ An increase in the time available to GPs to undertake more complex and/or chronic care for each medication review conducted by the IPP, although a considerable amount of time may be spent reviewing the clinical record and speaking to the patient this will be translated into one 10min GP appointment to gauge the time saved in practice 4. Reduced polypharmacy and reduction in unplanned A&E attendance and admissions encouraging adherence and concordance with an existing treatment plan, thus reducing the risk of medication related cause of A&E attendance and admissions. This may include review of all dossett box patients, to ensure the medication records are clear and synchronised. Interventions will be measured using the Croydon RIO model, which assesses the likelihood of an intervention preventing an unplanned admission. Contributing to and rationalising prescribing alongside advanced care planning. 5. Improved communication between the GP practice with, community pharmacy, care homes, hospitals (following patient admission and discharge), and with other interface care services the IPP would be well placed to engage with other HCPs to ensure that the patient record is accurate, and that changes are communicated effectively. This may often involve challenging conversations, which GPs do not have time to conduct within their clinic, or following up with other HCPs where information is not instantly accessible. This would overall lead to an improved quality of service and safe access to medication for the patient. Working in tandem with the Confederation care homes support service. 4. Project and Implementation Plan This is a joint programme working across the joint integrated system with benefits that will be across the health economy. The programme will be overseen by a project group which will be co-chaired by the CCG Head of Medicines Management and the Confederation Chair and will include relevant stakeholder representation. HPCC will be working with the relevant recruitment agencies e.g. NHS Jobs and LPC will advertise to community pharmacists via the Middlesex Group of LPCs to help with the recruitment campaign. The LPC will be engaged by reviewing applications for candidates prior to interview and will be a part of the interview process. Roles will be advertised on NHS Jobs and on the National Pharmacy Association websites and local networks e.g. via HCCG workforce development lead and LPC. Interview Panel: will consist of the Clinical Lead, HCCG Medicines Management Lead, Clinical/Community Pharmacist already working within General Practice, Middlesex LPC representative and HR advisor. Timeline anticipated to be within Q1 2018/19 with initial mobilisation in Q2 2018/19. The following outlines an initial project implementation plan which will be subject to change following the recruitment of the Project Manager. Page 5 of 8
Clinical Pharmacists Project Task ID Task Apr-18 May-18 Jun-18 Jul-18 IT 1 Scope IT Requirements Order laptops Order EMIS remote tokens Develop appointment templates Appointment templates set up on EMIS hub 2 Reporting Agree KPIs Agree how each KPI will be measured Report created on KPIs from EMIS or manual as necessary 3 Project Governance Convene stakeholder group Schedule project meetings Report to ACP Clinical Design Group Report to Primary Care Board 4 Process Identification of host practices Identification of supervising GPs Identify and provide training for supervisors Prescription process to be agreed Agree SOPs for clinical processes 5 People, HR & Development Recruit Project Manager Advertise positions Identify and interview appropriate candidates Agree T&Cs and write offer letters Agree service management support 6 Communication & Engagement Meet/Discuss the project with all practices involved Meet and write to all care homes involved in the project Agree with CCG PPIE Communications plan Develop practice questionnaire Develop questionnaire for care homes 7 Training Identify new systems training and training needs Training on EMIS Liaise with Health Education England regarding training plan for Clinical Pharmacists 8 Evaluation & Management Information Collect KPIs Capture patient experience Evaluate patient experience Capture and evaluate practice experience 9 Budget and management Information budget management system to be put in place Identify and track costings Create reports and systems for Management Information 10 Go Live Ongoing Ongoing Ongoing 5. Finance The funding provided by NHS England is a contribution towards the cost of recruitment and employment. The contribution will be tapered over a three year period, from the date of employment of the clinical pharmacist. For the Senior Clinical Pharmacists an annual salary of 63,000 has been assumed and 53,000 for Clinical Pharmacists. The following outlines the contribution requested over the next three years: Page 6 of 8
The initial paper reviewed by the Primary Care Board approved an in principle local contribution of 990,000 over the three year period as follows: Year 1 local contribution 220,000 Year 2 local contribution 330,000 Year 3 local contribution 440,000 NHS England contribution and expectation of local funding has been confirmed in the detailed offer and service specification as below.: Senior Clinical Pharmacist x 2 Clinical Pharmacist x 8 Year 1 Year 2 Year 3 NHS Hillingdo NHS Hillingdo NHS Hillingdo England n CCG England n CCG England n CCG 72,000 54,000 48,000 78,000 26,000 100,000 232,000 192000 160,000 264,000 88,000 336,000 Total 304,000 246,000 208,000 342,000 114,000 436,000 Therefore the total contribution from Hillingdon CCG will be 1,024,000 over the three year programme. Therefore, there is an additional local contribution requirement of 34,000 over the three year period of NHS England support. Year One: 26,000 Year Two: 12,000 Year Three: - 4,000 (less than initial Year 3 plan) It is our expectation that full recruitment for the entire duration of the programme is unlikely and that this 34,000 pressure outside of the original plan will be managed via inevitable short term vacancies. Year 4 and Beyond: Hillingdon Primary Care Confederation is a partner in the Hillingdon Health and Care Partners which is a collaboration of Hillingdon Hospital, CNWL FT and H4ALL (voluntary sector) to establish an Accountable Care Partnership in Hillingdon. We intend to work with our ACP partners to demonstrate the value that clinical pharmacists add across the health economy as part of the programme to establish a capitated budget aligned to an outcomes based contract. As we move towards an integrated care system approach over the 3 year towards all system efficiencies (including QIPP, CIP and other savings) the CCG hosted pharmacist roles will be utilised as part of that programme, working in an integrated way with the patient facing clinical pharmacists. Page 7 of 8
In the pilot practice, benchmark data has shown that a small list size of 4,200 patients would require at least 17-20 hours per week to make this financially viable whilst yielding positive returns by reducing workload. Therefore, in additional to the overarching plan, practices who engage with clinical pharmacists would be encouraged to be involved with QOF, LES and LIS and Medicines Management audits which would, in return, free up more GP time to manage the more complex medical needs that require longer appointments. This will demonstrate the effectiveness of the model to practices and form part of our longer term strategy for the clinical pharmacist workforce. 6. Governance Hillingdon Primary Care Confederation is a partner in the Hillingdon Health and Care Partners. Roll out of the Clinical Pharmacists would be part of the ACP Clinical Design Group work streams to ensure maximised opportunities to promote enhanced collaboration/integration across healthcare interfaces. A membership optimisation clinical working group will be formed with membership involving the Clinical Pharmacists and representatives from THH, CNWL, CPs, LBH, LPC and HCCG. The Senior Clinical Pharmacist and the Clinical Pharmacists will have a GP Clinical Supervisor at each practice they will be assigned to. It is envisaged that there will be at least one supervised session per week to begin with and dependent on the number of competencies being met the weekly session will move to bi-weekly and then monthly if appropriate. Please note to begin with there will be at least a 30 minute protected time for debrief. The Senior Pharmacists will have at least one supervised session per week with the Band 7 Pharmacists. Both Senior and Clinical Pharmacists will have access to the Confederation GP Clinical Lead for mentorship in terms of support and development. Senior Clinical Pharmacist Confederation Operations Group Attendance to be key in performance management and strategy development. The Clinical Governance for the project will be overseen by the Confederation Quality Governance Committee with regular detailed reports presented on overall progress to the CCG Medicines Management Committee. 7. Recommendation The primary care board is asked to approve the local funding of 990,000 over three years to match the NHS England Wave 4 funding to recruit, train and develop 10 clinical pharmacists for deployment across Hillingdon Page 8 of 8