Pharmacy: the first tier - a roundtable on the role of the pharmacist

The notion that pharmacists have much more to offer than many people realise has been an important part in Scottish Government strategies, none more so than in the 2013 ‘Prescription for Excellence’ vision and action plan, which enabled pharmacists to use their unique expertise in medicines to independently prescribe. 

It was a recognition of the pharmacist’s role in the wider healthcare diaspora, providing you with not just your prescription, but with wider pharmaceutical care.

But in the three years since, a period of great change in healthcare in Scotland, has the role of the pharmacist really been transformed? 

Progress towards the aims of Prescription for Excellence was the subject of Holyrood’s recent roundtable event in association with the Royal Pharmaceutical Society, which brought key players in pharmacy in Scotland together with prominent voices from the wider health and social care professional network. 

Scotland’s Chief Pharmaceutical Officer, Rose Marie Parr, said Prescription for Excellence was due to be “refreshed” in the wake of what she called three big “game changers” within the NHS.

As well as the integration of health and social care, which demands more inter-collegiate working, Parr also cited this year’s National Clinical Strategy, which has a focus on medicines safety and implications for governance and models of care. 

Chief Medical Officer Catherine Calderwood’s annual report ‘Realistic Medicine’, also published this year, was Parr’s third example. 

“It’s an update on professionalism for the medical profession. But it also challenges all of us, I think, to be more involved with patient care, with shared decision making, with actually trying to look at the things we know cause harm, waste and variation,” she said.

There are pockets of good practice, she said, but Prescription for Excellence was yet to become the norm.

Medicines remains one of the biggest spends in the health budget, but many patients don’t take theirs properly, with around half of patients with long-term conditions not taking the drugs they are prescribed. As well as implications for cost, this can be potentially dangerous. 

“There’s real issues there about how we speak to patients about medicines, so that’s what pharmaceutical care is to me,” said Parr. 

But while Prescription for Excellence formed an important part of empowering pharmacists to become independent prescribers and take a vital role in our NHS, have perceptions of the profession changed?

“It’s about education, it’s about competence, it’s about professionalism and also about how we describe ourselves to others,” said Parr, pointing out pharmacists are still defined by the building they work in, be that a hospital, a GP practice or a high-street shop. 

Pharmacy must be “overt” about the career framework, its expertise, the evidence and outcomes of medicines and communicate better with each other as well as with other professionals and with patients themselves, according to Parr.

A key challenge is access to information, said Dr John McAnaw, head of pharmacy for NHS 24 and chair of the Royal Pharmaceutical Society Scottish Pharmacy Board. 

To work effectively, he said, pharmacists need access to the Emergency Care Summary and the Key Information Summary, which collect vital information from a patient’s medical records. 

“I understand not all of that is going to be about medicine, but there will be some key information in there about individuals that, if pharmacists had access to that information, and other people in the health and social care network, could actually deliver more joined-up care,” he said.

But a change in perceptions of the pharmacist would be required. Irene Oldfather, director with the Health and Social Care Alliance Scotland, said generally there were “low levels of awareness” of what a pharmacist can now do. 

“If we were to speak generally to people, a lot of the feedback we get is that there’s still this view of pharmacists as suppliers of medicine, behind the counter,” she said. 

Dr Miles Mack, chair of the Royal College of GPs, said family doctors had experienced “some wariness” about the developing role of pharmacy within general practice. “Some of that is because roles are changing and at some points that makes us reconsider what our roles are, and how we fit into that team,” he said.

“We had a monopoly on this work, but actually, that’s not necessary, it’s not sensible. How do we move to a situation where we understand the differences?”

Dr Donald Macaskill, chief executive of independent care sector umbrella body, Scottish Care, agreed a “lack of clarity” around professional roles persisted. Social carers also struggled to be recognised by their peers in the professional network, he said. 

“We are all of us working towards a situation where there is complementary working around the needs of the individual to achieve the best possible outcomes, but we are some light years away from there, and we have to educate ourselves first of all before we can begin to expect massive leaps in terms of professional identity. 

“We’re getting there, but it’s going to take a lot longer than I think our politicians might imagine.”

Podiatrist Dr Joanne McCardle of the Allied Health Professionals Federation said AHPs don’t work as much as they could with pharmacists when reviewing patient activity. 

“It resonates with me when you said about perceptions of what you do, because we have the same issue within our profession, and it’s like if we’re not communicating who we are then how can we expect the public or even other health professions to know?” she said.

However, Ellen Hudson of the Royal College of Nursing said she had seen a growing recognition of the role of the pharmacist. “It’s really encouraging because when you see them in action, what they can actually do, a lot of it is at the sharp end of things, in and around medicines reconciliation,” she said.

Community nurses, she said, were becoming aware of the “treatment burden” of increasing numbers of medicines being prescribed, particularly in social care settings for the elderly. This adds to the workload of nurses and other professionals administering the drugs.

“The number of medicines and amount of time spent dispensing or administering or prompting or supporting takes away from a range of other caring activities or helping them to self-manage,” she said.

The CMO’s Realistic Medicine, it was agreed, can boost an agenda of ‘de-prescribing’ drugs. Oldfather argued the patient’s personal outcomes could drive it. 

“What should be important is that we give pharmacists and other health professionals the right tools to have the conversations,” she said. “Asking people themselves what’s important for them. For some people, it might be about not being in pain, but for a lot of people, it might be a different decision. It might be ‘I don’t mind some pain if I have fewer side-effects’.”

Macaskill said Scotland was “light years away” from the reality of outcomes-focused care for older people. “Not one” of the 33,000 people currently in a care home will have had an “individual outcomes-focused assessment”, he said.

“They will each be allocated a set amount of money with no recognition of their distinctive clinical or personal outcome needs. That’s the way the system’s set up at the moment, so the prospect of de-prescription, which I completely agree is absolutely critical, becomes remote.”

Macaskill quoted a nurse he had spoken to who had been forced to make a difficult decision on her medications round between supporting two patients who were to be transmitted to hospital or one who had only hours to live. “She has to do the two who need hospitalisation, and regrets the fact the woman dies on her own,” he said. “That’s the reality of nursing in a typical care home.” 

It was agreed pharmacists could make a big contribution to tackling this problem, but practice varied across the country. McAnaw outlined an example from Dumfries and Galloway where pharmacists were supporting and educating carers on the administration of medicines, rather than just prompting.

Parr said capacity was needed to enable pharmacists to ease the burden of medicines with polypharmacy and de-prescribing. “There’s just a waste of capacity everywhere and it’s unsafe,” she said.

In primary care, Parr said, building trust around the professional network can’t be expected to be built “overnight”. 

“Some of that will take time around trust and culture and that ability for doctors and other people to trust pharmacists with a clinical load. How do they know they’re experts in medicines unless they’ve actually worked with them on a patient level?” she asked.

Developing the role of the pharmacist as the first port of call for common clinical conditions, then, is one of the aims, including enabling closer working within GP practices and care homes as well as promoting community pharmacies as places where people can go first and foremost with health concerns. 

Oldfather suggested pharmacists needed to be seen as added value as opposed to “a second rate service” because the GP is too busy. 

And it would not need to be only about medicines. Pharmacists, she said, have become increasingly interested in the ALLIANCE’s ALISS system, an online resource of local community assets that can help people keep fit and well. 

“Pharmacy sometimes tends to be considered as an afterthought, whereas medicines are a thread that runs all the way through,” said Aileen Bryson, policy and practice lead at the Royal Pharmaceutical Society in Scotland. “We are part of the jigsaw and need to be integrated into each part of the journey, because we contribute all of the way along. But until we’ve got a culture of information sharing the IT won’t work because it’s just the enabler.”

Part of data sharing also lies in the informal conversations between professionals, according to McAnaw.

“I think it is shared intelligence of the patient and context they actually live in, not necessarily recorded data. It’s two professionals sharing the information they have to either solve a problem or perhaps prevent one.”

And how can pharmacists be given the space to have conversations with the public? Automation and the skill mix in the pharmacy team will be key, said Parr, while Hudson raised the importance of having a private clinical space in the community pharmacy where people would feel comfortable to talk to a pharmacist about their chronic condition. 

McAnaw said most pharmacies already have consultation rooms, but acknowledged that in some areas stigma was attached to their use. 

“It will always be a shop, won’t it?” said Mack, but added use of the clinical space should be encouraged. “Actually, as far as long-term relationships with patients, you must see them far more than GPs do. I’m seeing patients on average three to five times a year. They’re going to be going into the chemist a lot more than that, aren’t they?”

As a common front-facing interface, pharmacists can help ease the burden on the rest of the NHS and are in a perfect place to do it. What is still needed, then, to help it happen?

IT systems that talk to each other to enable effective data sharing would be a start.

Public awareness, including greater health literacy and understanding of the NHS, can be improved with effective messaging, suggested Bryson and Hudson.

The community pharmacy can be supported to refer someone to the right part of the NHS, said McAnaw, “promoting it as the first tier, perhaps, on the patient journey”. 

And while politicians can help change the perception of pharmacists, said Bryson, “pharmacy could do our bit ourselves”.

Both the benefits and potential harm of medicines can be better understood by all through the expertise of the pharmacist, said Parr. This could reduce the burden of over-prescribing. Drugs would then become “a much more realistic part of how we treat people, as opposed to the be all and end all,” she said.