30th September 2019
After qualifying I decided to become a community pharmacist and worked as a locum and manger for three years in Yorkshire.
I moved to London in 1990 and continued to work as a community pharmacist part time while I brought up my family. During this time, I felt I had neglected my career and needed to improve my clinical knowledge. I felt that completing a clinical diploma would be the best way to do this. During this time, the role of a primary care pharmacist or prescribing adviser as we were called in those days was just emerging and this fitted in with my family life, so I successfully applied for a job in 2005 for North Surrey PCT.
I thoroughly enjoyed this role and gained so much experience working in GP practices supporting prescribers and other healthcare professionals. I soon became the diabetes lead in the team and have been gaining experience in writing diabetes guidelines, educating clinicians and working with stakeholders to improve patient pathways for diabetes patients in Surrey. My work largely involved working with GPs and nurses to implement medicines management strategies but come up against a lot of resistance to change.
GPs would often say to me that the advice I gave was good in theory but that I did not understand the challenges GPs faced when patients are sitting in front of them.
This thought was in my head when I decided to become an independent prescriber in 2013. I missed patient contact from my community pharmacy days and felt that I could help patients with diabetes further by running clinics. As a prescriber, I felt that I had more credibility in my medicines management and teaching work. I could now say that I better understand the challenges prescribers faced and do face on a daily basis.
I have been running a weekly diabetes clinic as well as continuing with my medicines management work now for the last six years. My role as diabetes lead meant that I had accrued a lot of clinical knowledge and I started managing quite complex patients straight away. I wanted to manage patients on insulin and even though I taught clinicians on how to do this, I did not actually have a formal qualification to manage these patients. Therefore, I decided to attend Leicester University and complete the insulin management MSc module. The patients I see vary in complexity. I manage patients from those with pre-diabetes to those who are struggling to control their diabetes on insulin. I carry out a full diabetes check involving foot checks, taking blood pressures and medicines optimisation. My practice does not have a diabetes nurse, so the GP specialist and I are the only ones managing the complex patients. The other prescribers in the practice are confident to manage patients who are early in their diabetes journey but often refer to me if patients need escalation after metformin. I also carry out QRISK for my patients and prescribe statins where needed. I carry out the diabetes audits and prepare the practice for any CQC inspections. My practice is a training practice and I have been involved in educating the GP trainees about diabetes as well as other aspects of prescribing.
As a medicines management pharmacist I was always advising the use of cost effective medicines in any guidelines that I helped to produce. The advice was based on population medicine but as a practice pharmacist I had to make decisions for the patient in front of me. The two ways of thinking are not always the same and I constantly have to make decisions that went against guidelines which I produced. This dichotomy was a big challenge. Guidelines are for patients who do not have any other co morbidities or challenges, but my patients are from an area of deprivation and have many social and economic challenges that affect their ability to manage their condition. The increased number of choices for escalation of diabetes medications in recent years has meant that the answer to a problem is not always clear cut. The medicines management pharmacist within in me was sometimes fighting against my prescribing pharmacist side!
I made sure if I want to make a decision that does not truly fit in with guidance, I consult with the diabetes GP specialist in the practice. I also have a great support network of colleagues in secondary care who offer me support and guidance if I should be doubtful about anything, whilst always providing patient-centred and individualised care.
The challenge of keeping to time and managing patients in the short time given to me for consultations is something I still struggle with even after six years.
At the beginning of my time in practice as a GP clinical pharmacist I sat in with many clinicians and learned from them how to manage my time consulting. I learned to try out different consultation techniques and how to end consultations with patients who wanted to stay longer!
Handing out leaflets and sign posting patients helps a lot to reduce time. I have produced my own information sheets and use good online diagrams/tools to explain complex issues to patients. I am a great believer in educating patients to empower them to self-care better, but this can take up a lot of consultation time. For complex patients I am happy to bring them back for a follow-on consultation if needed.
Always regularly audit your work and reflect. This means that you are continually striving to improve. I find talking to my mentor and colleagues from other practices (keeping confidential patient information out of the conversation of course!) helps me to learn and improve too. I find attending education courses that are non-promotional helps me to keep up to date and allows me to network.
It is very important to make contact with all stakeholders and sitting in the clinics of other healthcare professionals can be a very valuable way of making and improving relationships.
Diabetes patients are at increased risk of cardiovascular problems so I would like to start focusing on optimising cardiovascular medication. I intend to start with hypertension and then move onto Atrial Fibrillation (AF).
I have carried out an audit using a patient questionnaire to see if my clinic has been a success and showed over 90% patients felt the clinic was an improvement on current services and they felt their needs were met.
I have had appraisals at the practice and we work closely with the district nurses for our insulin patients, which has increased the value of my input into the team. I only work one day a week so my impact on the patient outcomes has not been proven although I am about to undertake an audit of only my patients to see where I can improve patient outcomes.
As I aim to start managing the cardiovascular needs of my patients, I am going to find a relevant course that I can undertake. I lecture on cardiovascular medication but still feel I need a more formal qualification. I am tempted to do some more diabetes MSc modules at Leicester University as this can help me to ensure I am up to date with my diabetes as well as cardiovascular knowledge.
This list could be long but essentially clinical skills are very important and the basis of our work. In managing patients this is just the start though as I find it a big challenge to manage patients’ expectations and concerns. Negotiating, communication and organisational skills to name but a few are so valuable. IT skills are important and to know how IT can help you improve efficiencies. It is vital to network and produce a support network within and outside of the practice. Continually striving to improve is a must but try to be mindful of the challenges you face and make sure you set time aside for regular breaks.
I was blown away by their organisational skills and their support materials for the practice pharmacists. The teaching they provide is exceptional and very targeted to the needs of the practice pharmacists.
How scary writing my first prescription would be. Even though I wrote the local guidelines for years, taught clinicians, worked alongside diabetes consultants and advised specialist nurses about complex patients, writing my first prescription meant I had a hard time sleeping that night! I don’t think a lot of people realise the gravity of the situation and the responsibility we have as prescribers. Many pharmacists have approached me and asked how they can become independent prescribers, but I think we should have a good clinical knowledge base before we embark on becoming prescribers. This will help reduce the chance of errors and stress.
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