Advocate of the Year Dilip Joshi finds himself facing uncomprehending doctors who are asking why pharmacists are vaccinating “their” patients during the course of another month of flying the flag for the profession

Monday, February 3

I’m attending a borough prescribing meeting, ostensibly to consider medicines optimisation but a significant part concerns cutting costs. I reflect on what is the correct balance between using medicines effectively and reducing costs. There is GP software that focuses on cutting costs by suggesting switches to cheaper alternatives; often a brand is specified instead of a generic. I point out that this is not the panacea suggested by the software company, as patients who have been persuaded to take generics over many years are likely to be confused, especially if the change is temporary. Our contractors are also likely to experience instability in stock management, and switches attempting to achieve short-term savings are likely to be counterproductive in a volatile market that already suffers from stock shortages. There is also the issue of adherence (and hence, a reduction in optimisation) if a patient’s dosage regimen is altered from, say, once daily to three times daily purely on the basis of cost.

Wednesday, February 5

“We all have a story to tell and the Southwark health and wellbeing board wants to hear yours” are the words on Southwark council’s website, attempting to gather stories of 1,000 lives. This initiative is discussed at today’s meeting and is an attempt to understand how Southwark residents access healthcare. The idea has merit in that this is a serious attempt to understand how health and social care can be integrated to best effect. Plus, it involves a crossover of budgets for the first time and is operationally outside the ‘comfort zone’ of both healthcare and social care providers.

Thursday, February 6

I am chairing the LPC meeting this evening. The routine items of business are covered fairly quickly as the focus is the contractor event we are holding on Monday.

Monday, February 10

Over the years, our LPC has held many contractor support events addressing key issues of the day. This evening’s event includes three presentations and a Q&A session at the end, in which we have invited two NHS England delegates and a CCG pharmacist, in addition to our speakers, to participate. Leyla Hannbeck, of the NPA, presents the new GPhC requirements and the excellent support materials developed by her team to help members prepare for inspector visits. Several members complain about the time visits took and felt inspectors were unsupportive.

_{At the contractor support event (left to right): Yours truly, Ash Soni, RPS, David Tamby Rajah, NHS England, Tushar Shah, NHS England, Finlay Royle, CCG Pharmaceutical Advisor, Indrajit Patel, PSNC}

Colleagues from NHS England try to strike the right balance between being supportive and talking about sanctions for contractor shortcomings when asked why health promotion campaigns were rushed through during December. The general feeling was that they were trying to tick their boxes. In any case, they had relented and extended previously set deadlines. I wonder whether any amount of time or supportive measures might not be enough for a small number of contractors and how this might let the majority of contractors down in the new commissioning environment.

The event turns out to be one of our most successful ever with well over 100 attending and giving very good and excellent ratings on our feedback forms. In the post-event discussions, LPC members again recognise the downstream support contractors will need in order to cope with the regulatory burden, service delivery, staff development (including training) and other day-to-day activities that take time away from direct patient care. They resolve that this must be a very high priority for the new committee taking office in April.

Friday, February 14

I’m attending a second meeting with the London-wide local medical committee at BMA House. They had asked to meet our LPC, initially to discuss why our contractors were vaccinating “their” patients. It was clear from my answers about not meeting targets, offering the public wider choice and access that they just do not understand the service. We discuss various scenarios that could develop, including new entrants that may have excellent business skills but are not experts in healthcare provision and might employ our members as providers, having secured contracts through Public Health England and others. I suggest that we need to work with Pharmacy London at a strategic level and at local level for collaborative engagement and possibly joint ventures.

Tuesday, February 18

I am the pharmacist on duty. In an MUR, I notice my diabetic patient does not request her test strips very often. When asked, she says she does not bother as she has been feeling all right, but admits that she often forgets to take her medication and her sugar levels are not always well-controlled, according to the diabetes nurse at the surgery. I reflect on the number of issues this patient raises. Adherence is a major issue and is likely to be as much related to behavioural change as understanding how the medicines work.

Previously, I have carried out an audit for diabetic patients at a surgery, having been given access to the surgery-based computer system. My task was to ‘flag up’ unusual patterns of repeat prescribing based on what was requested by patients, so that a ‘pop-up’ alert was raised the next time the GP saw the patient. Interestingly, although excessive use of test strips is easy to pick up, lesser use might indicate a poor testing regimen but could also indicate adequate control. I am once again reminded that clear-cut conclusions are not always possible. Appropriate interpretation of findings cannot simply be made using computer-generated algorithms, but instead requires the skill of well-trained practitioners experienced in speaking to patients on a daily basis.

Thursday, February 27

I’m at a skill mix meeting to explore the support that trained staff can provide for newly-commissioned services in Lambeth. In my pharmacy, the health champion has become an essential member of the team for recruiting patients as well as providing smoking cessation services, finding flu vaccination information and obtaining preliminary data for NHS Health Checks, such as height, weight, BMI, waist circumference and blood pressure. Pharmacists will need to learn to delegate more effectively in future and show leadership to ensure well-trained staff members are given the opportunity to develop.