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Better prescribing: Better practice

Why was the initiative launched?
Making it happen
The practice-pharmacist role
What has been achieved?
Tips for success
Next steps
For more information contact
ImpAct Bottom Line

Exploring the benefits of a pharmacist's role in primary care at Northgate Medical Centre, Walsall

Why was the initiative launched?


In the early stages of the development of GP fundholding at the Northgate practice it became clear that an important indicator of success would be how the practice handled prescribing. Could they manage this aspect of their practice effectively? The challenges were about the way the practice obtained and used advice and information about medicines. Creation of a practice formulary would be a key step.

The problems would be about time, a scarce commodity in primary care, and about expertise because GPs were not trained in the detail of prescribing policy-making and formulary development. Employing a pharmacist made sense. The opportunities presented by the introduction of fundholding offered an opportunity to do it. The Northgate practice with five GPs decided something had to be done.

Making it happen


One of the partners, Dr Denys Wells, approached the Good Hope Hospital, Sutton Coldfield, to second one of their pharmacists to the practice. The initial request was for some part-time help to set up a practice formulary. But there emerged a feeling that a practice-based pharmacist had more to offer than the limited task of setting up and maintaining the formulary.

Initial discussions encouraged those involved to think through the role a practice-based pharmacist could play. Clarity about the objectives of more rational and effective prescribing would be required. The practice agreed that the key criteria must ensure that recommended medicines were:


The practice-pharmacist role


Discussions about overall objectives formed the background for a business plan for the proposal. This described four distinct roles for the practice-based pharmacist, ie:

  1. Administrative: centred on the creation and maintenance of the formulary. Other tasks would include the management of repeat prescribing and ensuring that medication records were kept up to date. Better use of PACT data, with analysis and discussion, would be possible.
  2. Clinical: to help improve the quality of care to patients. The tasks would include providing information about drugs to general practitioners and counselling for patients. It would also include monitoring drug therapy and adverse reactions. Time would also be available for direct patient care at anti-coagulant and migraine clinics which would help save GPs' time!
  3. Interface: to improve liaison with clinicians in secondary care. The aim would be to ensure continuity of care after discharge or treatment as outpatients.
  4. Research: to help improve the quality of prescribing in the longer term, for example through involvement in research studies and medical audit.

The practice now knew what it wanted to achieve; the next step was to see if it could find the right person for the post. There were few doubts that the new post was a challenging role and would require someone who had:


Local enquiries identified Marion Bradley, who was then working in the Pharmacy Department at Good Hope Hospital. She stared work with the practice in 1994.

What has been achieved?


The first task, creation of a practice formulary took about three months. PACT data and other information about effective medicines provided its basis. The aim was not to provide a narrow straight-jacket for partners but to provide a framework for better prescribing. The criteria proved to be helpful in assessing content. While some preferred medicines were included initially other oddities were excluded. The formulary is now well regarded and used. It is kept up to date. It is proving to be an important aspect of promoting evidence-based practice.

The post has many practical signs of success, with the practice-pharmacist a respected member of the team. Pharmaceutical care of patients has improved and time is being saved for both partners and practice staff. For example, the practice-pharmacist rather than GPs now runs anti-coagulant and migraine clinics. Much of her time is spent answering enquiries from patients about medicines. The service has been particularly well received by patients, grateful comments from patients and carers include 'I'm very pleased with the speed and kind attention I now receive' and 'I can call Marian if I'm worried about Mum'.

The practice pharmacist also manages repeat prescribing. A recent initiative, in partnership with community pharmacists, to change to salbutamol CFC-free inhalers went well: a consequence of the good local working relationships. Arrangements have also been made to ensure more effective management of prescribing for patients in local nursing and residential homes with important changes being achieved. The practice pharmacist provides a formidable contact for local representatives from pharmaceutical companies. Because of other pressures, it has not proven possible to devote significant time to the proposed research role although contributions have been made to a number of research studies, related to the use of statins and endoscopy.

One regret is that the practice did not from the outset set up baseline indicators to monitor and measure the improvements in prescribing quality they have been able to achieve. They have to use broader costings to see the overall effect. These are encouraging but there is a danger that their work is seen to be about saving money! Over the last four years prescribing costs have been consistently about 20% below health authority and national averages (Figure 1). Practice prescribing costs have grown by under 6% a year, compared with local and national growth rates of about 9%.





Tips for success



Next steps


The initiative has proven the value of reliable, on-site, prescribing advice in primary care. More effective prescribing and better management of resources can be achieved. But the end of GP fundholding signalled the end of the scheme. Most practice pharmacists have since taken up posts as PCG pharmaceutical advisers. Marian Bradley now tries to combine the practice-based role (working with three practices) with that at PCG level. The many demands do not however allow the previous detailed attention. The lessons from this initiative suggest that this type of support will be important at practice level as PCGs take on their commissioning role. But there are unanswered questions:


For more information contact


Dr Denys Wells or Marion Bradley
Anchor Meadow Health Centre
Aldridge By-pass, Aldridge
Walsall WS9 8QD

Telephone 01922 450900 Fax 01922 450910
Email BradleyM@gp.walsall-ha.wmids.nhs.uk

The following material is available:

Note about the practice pharmacist role
Articles and papers about the practice-pharmacist post



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