Clinical leaders: Pharma on the front line

Imagine if there was a huge resource within the NHS: an army of highly trained staff who have regular contact with patients with long term conditions.

Imagine if this contact was usually brief and its potential largely untapped.

Imagine if the work of these staff was opened up so they could make an impact on how these patients took their medication and how often they were admitted to hospital.

‘Dispensing is usually a brief interaction focused on accurate, legal provision of medication. But it could be very different’

We are talking about pharmacists, of course - particularly those in community pharmacy. The NHS needs to grow its capacity without growing costs, and an elegant solution is to allow pharmacists to make the best use of their clinical skills to take on some of the duties of doctors and nurses.

To achieve this, a shift in mindset is needed across the NHS, and stronger leadership from within pharmacy.

• Also this week – Hard to reach groups: Making a call on the mobile
• Trusts can integrate pharmacy into community care
• Avoid medication inaccuracies with new technology
• More pharmaceuticals news and resources

Tablet application

One starting point could be the management of chronic conditions. Through dispensing, pharmacists have more contact with patients than all other healthcare professionals put together, so their potential influence is huge.

Take diabetes, for example. Diabetes UK estimates this condition costs the NHS up to £1.5m an hour - or 10 per cent of the health budget. There are huge issues around non-compliance in people with diabetes, with a dire impact on health outcomes.

‘One thing that helps people control their disease is engagement with people with similar conditions’

Dispensing is usually a brief interaction focused on accurate, legal provision of medication. But it could be very different.

It is an opportunity to, for example, create a constructive dialogue about how best to manage hypoglycaemic episodes, and how to get the most from insulin.

It could even be an opportunity to touch on the real value to the patient of their health, such as avoiding the sheer unpleasantness of a “hypo”, or the ability to socialise and counteract loneliness.

Two way process

David Terry, director of the Academic Practice Unit at Aston University, says: “Dispensing needs to be two way. It is not enough just to give the facts. We have to get back from a patient with diabetes what they intend to do. What’s the real position? As pharmacists we are as well placed as anyone to do that.”

Fostering patient communities can also have a huge impact.

Mark Robinson, a partner in the Medicines Management Partnership, says: “One thing that helps people control their disease is engagement with people with similar conditions.

‘If pharmacy was like driving a car, we would be very good at looking at the dashboard but not out of the window’

“Some of the solutions people come up with you wouldn’t think of in a hundred years, but they work for them. I would like to see community and hospital pharmacy engaging populations with diabetes to create a support programme.”

This vision is gathering force following the Now or Never: Shaping Pharmacy for the Future report by the Royal Pharmaceutical Society’s commission on future models of care delivered through pharmacy. Published in November, it says pharmacists need to embrace a broader role as care givers, and calls for stronger leadership within the profession.

Self-image problem

So what are the barriers? The discipline itself lacks confidence, and there is a common concern among individual pharmacists that they do not have enough expertise in specific illnesses.

Pharmacy is thought by some to be inherently technical and geared towards detail, so the big picture thinking so vital to leadership may not come naturally to members of the profession.

Ray Fitzpatrick, clinical director of pharmacy at the Royal Wolverhampton Hospitals Trust, says: “A colleague of mine says if pharmacy was like driving a car, we would be very good at looking at the dashboard but not out of the window.”

Dr Terry adds: “Most of our lives we’ve spent learning to be clinical pharmacists. We’ve got the technical skills. What we lack are the softer skills: getting your team to accept change and selling the vision.”

‘We want the patient with diabetes to become the expert and gain confidence and competence in managing their own condition’

If pharmacists themselves need a change of attitude, then it is no surprise that NHS Alliance chief executive Rick Stern argues that the rest of the NHS does too. He says: “Managers in the NHS don’t tend to think automatically about pharmacy and its potential. Commissioners are probably not ready at the moment. It’s been quite a struggle in the last year to work in a new way with their own practices who make up clinical commissioning groups.”

But given the financial challenges facing the service, the case for overcoming the barriers is urgent. So what can be done?

Frontline pharmacists do not need to be experts, he says, but this new role is about skills rather than knowledge - forming relationships and employing the psychology of behaviour modification.

As Mr Robinson puts it: “We want the patient with diabetes to become the expert and gain confidence and competence in managing their own condition. There is nothing more powerful than an expert patient.”

Influencing others

The Centre for Pharmacy Postgraduate Education has launched a 90-day course in consultation skills for pharmacists, so help is at hand.

Pharmacists may not be groomed for leadership but they do have some natural advantages when it comes to influencing senior colleagues, Professor Fitzpatrick says.

“Pharmacists are in a very, very good position. While we are clinical, many of us also have a sense of business,” he adds. “Managers understand that medicines cost money. I know that’s the button to press if I want to get senior management engagement.”

‘Managers need to stand in a community pharmacy and survey their territory - that is a place they can commission services from’

The other big contribution of pharmacy to the business of the NHS is the mitigation of risk.

“We are the safety net when it comes to medicines. That gives us quite a strong voice and clinical pharmacy is the working out of that risk agenda,” he adds.

So once pharmacists have convinced their chief executive, where do they go next to flesh out this broader clinical role and deliver the seamless medicines optimisation that will keep people out of hospital?

Mr Robinson says: “Managers need to stand in a community pharmacy and survey their territory - that is a place they can commission services from. They then need to talk about what is possible and create a plan and a vision.”

In an ideal world, hospital pharmacists will communicate with community pharmacists to direct their effort towards the patients who need it most.

There are innovative pharmacy projects taking place all around the country, Mr Robinson says, including: pharmacists running minor injury and ailment clinics, being on GP out of hours teams and working with patients with long term conditions. But these are too fragmented. To achieve a tipping point and transform the profession, they need to happen simultaneously in one locality.

Mr Stern adds: “It will take a lot of time and new ways of working, and that is difficult. But over the next few years pharmacy is going to shift considerably. It won’t be making money on procuring and distributing medicines, it will be about how pharmacists can work with communities and improve their health. Managers and commissioners are not widely aware of the opportunity, but it wouldn’t be too hard to persuade them. There is a huge saving in this.”

• This article is based on a report of a session at the Clinical Pharmacy Congress, which took place on 24-25 April 2014 in London. Sanofi sponsored the session and contributed to the questions directed at the panel. HSJ attended the event, wrote an independent account of the discussion and retained editorial control of this special report.