Are pharmacists a solution to the GP workload crisis?

Primary care services continue to face growing and unprecedented demand. In 2020, it was estimated that 29.1 million consultations take place in general practice every year in Ireland.1
The increase in demand is due to a culmination of several factors, including ageing populations, increasing multimorbidity, initiatives to move care from hospitals to primary care and rising public expectations.2 This is further compounded by difficulties with recruitment and retention of general practice staff.2 To combat the rising pressure in general practice, pharmacist integration into practice teams has been implemented in several countries worldwide.
In 2016, the National Health Service in England (NHSE) ran a successful national pilot scheme of practice-based pharmacists and now more than 3,200 pharmacists work full-time in primary care networks across England.3,4 Practice-based pharmacists in England perform a wide variety of roles. The BMA lists the following as practice-based pharmacists’ responsibilities:5

• Working with GPs and patients to address medicine adherence
• Reviewing patients on complex medicine regimens
• Triaging and managing common ailments
• Responding to acute medicine requests
• Managing and prescribing for long-term conditions
• Dealing with medication for patients recently discharged from hospital
• Delivering repeat prescription reviews
• Being a point of contact for all medicine-related queries
• Audit and education.

An evaluation of the pilot by the University of Nottingham concluded that pharmacists in practices contributed significantly to patient safety, medicines and prescribing expertise, support with prescribing tasks, support for patients with chronic diseases and practice capacity. Most GPs who took part in the pilot said they would keep their pharmacist in the practice even after the funding expired, highlighting the value the pharmacist brought to the practice.
Training and additional skills development were also a key part of the pilot. During the pilot, pharmacists completed an 18-month workplace-based development and education scheme which focused on skills in clinical assessment, examination and monitoring; consultation; common ailment management and independent prescribing.6 In January 2019, a new five-year GP contract was agreed with the NHS and the British Medical Association’s General Practitioner Committee.7 This contract made funding available to support the recruitment and retention of general practice-based pharmacists.
Primary care networks availing of the scheme can claim reimbursement of 70% of the ongoing salary costs of employed pharmacists. Prior to taking up a post in a practice, pharmacists must complete the Primary Care Pharmacy Education Pathway,8 an 18-month education programme that also includes independent prescribing training.
Numerous trials of practice-based pharmacists have taken place to explore the potential benefits of the role. In 2014, a review from Edwin Tan and colleagues concluded there were significant improvements in patients’ BP, glycosylated haemoglobin, cholesterol and cardiovascular risk score in general practices with an integrated pharmacist.9 A review from Emily Hayhoe and colleagues in 2019 showed that pharmacist integration into practices resulted in reductions in GP appointments, ED visits and medication costs.10
Despite the evidence base for the role, the integration of practice-based pharmacists in Ireland to date has been somewhat limited. In 2020 however, a group of researchers in RCSI published the results of a feasibility study that integrated pharmacists into general practice teams.11,12 During the study, pharmacists joined practices for six months, where they performed medication reviews, provided prescribing advice, conducted audits and practice-based education.
Medication changes made during the study equated to around €57,000 in cost savings, assuming they persisted for 12 months. The role was also rated as acceptable to most patients and GPs and showed potential to reduce inappropriate prescribing. The group at RCSI has also published a protocol for a randomised controlled trial (RCT) of practice-based pharmacists that is currently underway.13
A second initiative taking place is the Stimulating Innovation in the Management of Polypharmacy and Adherence Through the Years (iSIMPATHY) project, taking place in Scotland, Northern Ireland and several counties in the Republic of Ireland. It focuses on the delivery of patient-focused medication reviews by pharmacists in collaboration with GPs. The reviews draw on the Scottish polypharmacy guidance and follow a seven-step approach.14 An interim analysis of the 1,200 medication reviews conducted so far looks promising, with €261 saved on average per review. The project was deemed highly acceptable by GPs and patients, and shows positive effects on patient safety, quality of care and quality of life.15 The results of these initiatives will be instrumental in informing future practice-based pharmacist roles which, in Ireland still remain largely undeveloped.

References

1. Collins C, Homeniuk R. How many general practice consultations occur in Ireland annually? Cross-sectional data from a survey of general practices. BMC Family Practice. 2021 Feb 20;22(1):40. 
2. Baird B, Charles A, Honeyman M, Maguire D, Das P. Understanding pressures in general practice. London: The King’s Fund. 2016 May;100. 
3. Burns C. Number of pharmacists working in primary care networks has increased by a third over past year [Internet]. The Pharmaceutical Journal. [cited 2022 Sep 6]. Available from: https://pharmaceutical-journal.com/article/news/number-of-pharmacists-working-in-primary-care-networks-has-increased-by-a-third-over-past-year
4. Boyd M, Mann C, Anderson C, Avery A, Waring J. Evaluation of the NHS England Phase 1 pilot: clinical pharmacists in general practice. International Journal of Pharmacy Practice [Internet]. 2019 Feb 3 [cited 2021 Sep 1];27(S1). Available from: https://nottingham-repository.worktribe.com/output/1835734/evaluation-of-the-nhs-england-phase-1-pilot-clinical-pharmacists-in-general-practice
5. British Medical Association. Employing clinical pharmacists in GP practices [Internet]. The British Medical Association is the trade union and professional body for doctors in the UK. [cited 2022 Sep 6]. Available from: https://www.bma.org.uk/advice-and-support/gp-practices/employment-advice/employing-clinical-pharmacists-in-gp-practices
6. Centre for Pharmacy Postgraduate Eduation. Clinical pharmacists in general practice education pathway [Internet]. [cited 2022 Sep 6]. Available from: https://www.cppe.ac.uk/career/cpgpe/clinical-pharmacists-in-general-practice-education
7. NHS England. Briefing on Clinical Pharmacists and the Network Contract DES [Internet]. [cited 2022 Sep 6]. Available from: https://www.england.nhs.uk/gp/investment/gp-contract/briefing-on-clinical-pharmacists-and-the-network-contract-des/
8. Baqir W, Child A, Lisk C, Pinney H, Shaw N, Sims L, et al. Primary care pharmacy education pathway [Internet]. Centre for Pharmacy Postgraduate Education; 2019 [cited 2022 Mar 15]. Available from: https://www.cppe.ac.uk/wizard/files/pcpep/pcpep-brochure.pdf
9. Tan ECK, Stewart K, Elliott RA, George J. Pharmacist services provided in general practice clinics: A systematic review and meta-analysis. Research in Social and Administrative Pharmacy. 2014 Jul 1;10(4):608–22. 
10. Hayhoe B, Cespedes JA, Foley K, Majeed A, Ruzangi J, Greenfield G. Impact of integrating pharmacists into primary care teams on health systems indicators: a systematic review. Br J Gen Pract. 2019;69(687):e665–74. 
11. Cardwell K, Smith SM, Clyne B, McCullagh L, Wallace E, Kirke C, et al. Evaluation of the General Practice Pharmacist (GPP) intervention to optimise prescribing in Irish primary care: a non-randomised pilot study. BMJ Open. 2020 28;10(6):e035087. 
12. James O, Cardwell K, Moriarty F, Smith SM, Clyne B. Pharmacists in general practice: a qualitative process evaluation of the General Practice Pharmacist (GPP) study. Fam Pract. 2020 Oct 19;37(5):711–8. 
13. Croke A, Moriarty F, Boland F, McCullagh L, Cardwell K, Smith SM, et al. Integrating clinical pharmacists within general practice: protocol for a pilot cluster randomised controlled trial. BMJ Open. 2021 Mar 1;11(3):e041541. 
14. NHS Scotland. Polypharmacy Guidance Realistic Prescribing 3rd Edition 2018 [Internet]. 2018 [cited 2022 Sep 6] p. 85. Available from: https://www.therapeutics.scot.nhs.uk/wp-content/uploads/2018/04/Polypharmacy-Guidance-2018.pdf
15. Health Service Executive (HSE) iSIMPATHY Project Management Team. iSIMPATHY Interim Report April 2022 [Internet]. 2022 p. 1–21. Report No.: 1. Available from: http://hdl.handle.net/10147/631776