16th April 2018

Insight from Siân Rae

Time in general practice

2.5 years

Location

Salford, Greater Manchester

Qualifications

  • MPharm, Clinical and Health Services Pharmacy Diploma (both University of MaMPharm
  • Clinical and Health Services Pharmacy Diploma (both University of Manchester)
  • Currently undertaking Non-Medical Prescribing course in University of Salfordnchester
  • Currently undertaking Non-Medical Prescribing course in University of Salford

Current Role

Practice pharmacist directly employed by a community interest company delivering General Practice services across three sites locally.

My life before becoming a pharmacist in GP Practice

I spent the first 5 years of my career working in hospital pharmacy, covering the usual array of medical and surgical specialties as a rotational pharmacist. I also spent a couple of years working in aseptics making chemotherapy and TPN, where I learnt to write protocols and develop SOPs. I then moved on to a Medicines for Older People ward and delivered the pharmacy service for our local hospice.  Clinically these specialties work well together, and I developed my skills in the holistic care of patients who do not always fit within the criteria of NICE guidance and clinical trials. It also allowed me to work more autonomously and develop new processes individual to the needs of the hospice. These skills left me well placed to transition into primary care when I saw a job advert for a full-time practice pharmacist from a company who seemed to really understand the value we could add.

GP Practice experience

Myself and a colleague with a community background provide a service to 16,000 patients in areas of Salford with historically high rates of long term conditions and co-morbidities.

  • Clinically, I review patients with long term conditions, particularly cardiology and diabetes, and polypharmacy. I reauthorise repeat prescriptions and process clinical post, concentrating on hospital discharges. I manage the monitoring of high risk and shared care drugs, including methotrexate and DMARDs and atypical antipsychotics. We have developed an internal audit tool which I run every month and allows me to quickly review the vaccination status and monitoring results of my 42 patients on methotrexate. I can easily see if there are any out of range or out of date results which I can then take appropriate action on.
  • Operationally, we ensure we are meeting our QOF and Salford Standard targets and improve processes in order to ensure that we are providing the best care possible to patients, pro-actively. These include processes such as the annual review templates for practice nurses and HCAs, repeat prescription processing, clinical post workflow and read coding. Also part of the GP contract this year was the new electronic frailty index (eFI). This specifies that severely frail patients should have an annual medication review, with pharmacists well placed to deliver this. The training delivered by the i2i Network really opened my eyes to the expanse of resources out there to guide us in this, and confirmed my position on treating patients holistically not just to NICE and QOF tick boxes.

Key examples of personal challenges of practice pharmacy – what were they and how did you overcome them? (including skills, knowledge and training)

Challenge #1

My biggest worry moving from a hospital team to a new role in primary care was the potential for isolation, and not having a network of people who have tread the boards before you (although I won’t lie that I don’t enjoy feeling ahead of the pack in a developing field).

Solution

Having two pharmacists with different backgrounds (community vs. hospital) has been invaluable for the practice, as well as for the two of us who are always helping each other develop and grow.  We separate our workload out between us to utilise our skillsets most effectively.  For example, my colleague is best suited to processing prescription reauthorisation requests and I discharge summaries. She has better knowledge of the community pharmacy services and contracts and I have more clinical experience. Through the i2i Network workshops we now also have an extended network of local directly employed pharmacists who we can lean on for advice and a listening ear.

Challenge #2

Working without a prescribing qualification.

Solution

The obvious answer is to become a prescriber however I would not say it is an essential part to the job. The challenge comes in making decisions as a healthcare professional and having to then pass it on to a prescriber. While the legal responsibility lies with the prescriber, I ensure that I document as clearly and concisely as a pharmacist can (we do like detail!), in order to give the prescriber confidence in my decision. I would recommend any new non-prescribing pharmacist to agree a defined pathway for these decisions early.

Key Messages

I suppose the common theme here is teamwork and open communication with your colleagues. Finding the right practice and team where you all understand each other’s positions puts you in good stead for achieving job satisfaction.

What are your current priorities / key areas of focus?

I am currently writing a plan to more pro-actively review patient’s medications after they come in for their physical annual review. We aim to hold pharmacist-led medication review clinics which patients are invited to after their annual physical health monitoring. We will concentrate on the frailest patients with the highest levels of polypharmacy in order to optimise their medications, reduce medication burden, reduce medication related hospital admissions and plan monitoring and prescriptions for the year. This should reduce the medication reauthorisation burden further for the GPs.  It will also provide patients with another healthcare professional that they can have access to, for longer than ten minutes, providing them with expert medication advice and satisfaction.

How have you demonstrated impact and value in your practice?

We provide a quarterly report, the same as other teams in the company. This includes how many hours we have saved the GPs in reauthorisations, clinical post and seeing patients (6.6 hours a day) but also the unmeasurable qualitative factors such as quality improvement, audits, safety alert actions, education and information sharing we have provided etc. It’s amazing to get it all down on paper and demonstrate the wide variety in what we do, not just to our managers but to ourselves. I keep the report to two sides of A4 and like to stick in a graph with a big red line going up where I can!

What development do I need / am I undertaking at this point in my journey?

I am currently undertaking the Non-Medical Prescribing course which has been an eye-opener in terms of just how many soft skills pharmacists are lacking. We have repeatedly been informed of how bad we are at reflective practices. I didn’t believe them until I wrote 500 words of description without reflecting on a single point.

The sessions where I am learning the most are ones regarding health promotion, health coaching and crucially the non-pharmacological management of conditions. Understanding the process of diagnosis and lifestyle management before prescribing has significantly challenged my previous way of working, and will have a big impact on my patients.

What skills or competencies do you feel are important to have in your role as a practice pharmacist?

  • Good clinical knowledge of how to manage long term conditions, not only acutely but exactly what the title implies – long term.
  • Change management – setting up new processes and services without involvement of key stakeholders is a recipe for disaster. The i2i Network workshops have not only provided me with up to date clinical knowledge – they guide you through the minutiae of how to put clinics into action.
  • Confidence to lead your own service without senior pharmacists there to follow.

What has been your perception of the i2i Network?

Before attending my first workshop, I thought I would go along to another study day that reminded me of the NICE guidance for pharmacological management of diabetes. I couldn’t have been more wrong. Yes, we were provided with clinical management scenarios from expert pharmacists but also gained in confidence with access to the tools and templates to be able to put these into practice alongside a peer network to support us moving forward.

I wish someone had told me………

That pharmacy isn’t just community or hospital. You don’t leave your skills and knowledge behind you as you transition into a new field, you bring it all with you and apply it to what you have in front of you.

And primary care provides a much better opportunity for a cup of tea whilst you work and leaving at 5 o’clock. Most of the time.

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