Striding out in Doncaster
The winner of the Pharmacist of the Year Award at the Independent Pharmacy Awards last year was Laura Sharp of Doncaster. She has made great strides in developing clinical services and is now part of a rare breed of pharmacist who combines independent community pharmacy with working in a GP practice. Douglas Simpson went to Doncaster to find out more about this young member of the profession
Laura became a pharmacist because of family connections. Her father David bought his first pharmacy 30 years ago. There are now three Sharp pharmacies in the Doncaster area. Laura says: â€œI grew up in a pharmacy. I remember as a toddler pressing the buttons on the till.â€ But a career in pharmacy was not automatic. â€œI also sing, so the question was whether I had a future in opera or whether to become a pharmacist. I felt that pharmacy was a good career.â€
Laura graduated with a first from Nottingham University in 2011. Preregistration was not in the family business but with Weldricks, the Doncaster-based small multiple. â€œMy father thought it really important that I got experience in other pharmacies.â€
In reality, though, that experience had started a year earlier. In her final year at Nottingham, she worked on an audit of erectile dysfunction services in a fourmonth placement with Boots. This was for a dissertation. The project went well and Laura believes that her work was used to inform changes in future services.
Laura enjoyed her preregistration year with Weldricks and has warm words for her tutor Robin Carnegie: â€œIt was very hands on and really good preparation for me going out and taking responsibility as a pharmacist.â€
After registering, Laura started a PhD at the University of Nottingham. The topic was the role of community pharmacy in out-ofhours services. She collected, she says, a lot of good data, including that 8% of what was seen in A&E could be dealt with by community pharmacists. She was about to embark on qualitative research, watching how pharmacists worked with people out of hours, but the situation in OOH services changed and the research got overtaken by events. So she drew a line under it.
Laura had continued working with Weldricks in the meantime. She did domiciliary MURs identifying medicines that could cause falls, as part of a local falls prevention service. Suggestions were made to GPs for changes to medication where necessary. â€œThat really built up my confidence clinically. I would see some of the patients later and see that the effect on them had been really good.â€
Work with Weldricks ended in June 2016 when Laura rejoined the family business. She continued to provide all the clinical services she had been doing at Weldricks: the home visits, the MURs and so on. But, as an independent prescriber, she has been able to spread her wings through the provision of such services as a travel vaccination clinic and a private minor ailments service.
Freedom as prescriber
Being a prescriber means that she does not need a patient group direction to enable her to operate and gives her greater freedom of action with minor ailments. This service is for people do not want to sit in A&E for hours. â€œIf I can deal with the problem I do.â€
The local CCG used to provide a minor ailments service but it became a victim of its own success and was decommissioned when it ran over budget. A scaled back service limited to OTC medicines now sits in its place.
Lauraâ€™s prescribing skills also come into play in the local Yorkshire â€˜Smokefreeâ€™ smoking cessation service. Smokers who have a history of depression at any stage in their lives canâ€™t be prescribed Champix under the PGD that is operative in the area. Laura is able to prescribe the tablets after completing a risk assessment and supervising users closely during their course of treatment. She has dealt with over 50 patients so far.
How did she become an independent prescriber? â€œI did a distance learning course with the University of Keele and had Dr Puvanasundaram Umapathee at Bentley Health Centre (which is in the Doncaster area) as a local supervisor. He was really supportive.â€
She had struggled to find a â€œforward thinkingâ€ GP who would help her. Some local doctors did not see the point of having a pharmacist prescriber. What did she learn from Dr Umapathee? â€œI learnt consultation technique, clinical skills, how to check blood pressure, and basic examination of patients. There were a couple of patients who were agreeable to me examining them.â€
As a prescriber, does she feel that she could do a lot more? â€œYes, there are many conditions we could treat but the NHS contract does not allow us to do so. We end up referring people to other services where the cost is greater.â€
What sort of conditions does she have in mind? â€œCommon ailments such as impetigo that need treatments stronger than OTC medicines.â€
Any plans for the future? â€œWe are working on improving the minor ailments service. I did suggest that the CCG try to use the prescribers in Doncaster and have a â€˜pharmacist prescribersâ€™ minor ailments service. There are quite a few pharmacist prescribers about and we are growing in number. â€œAnd we have just started a South Yorkshire Practice Pharmacists Group too. We have got six members so far.â€
Do pharmacist prescribers feel frustrated that they do not have enough to do? â€œYes. A lot of prescribing pharmacists are moving into working in general practice now. Many feel there is no benefit in being a prescriber in the community and they need to find other ways to use and improve their skills.â€
Laura herself works with two groups of GPs. â€œIt is a completely different skill set to the one you use in pharmacy. It is good having experience of community pharmacy and general practice. You can see both sides of the problem. I have been able to help community pharmacists local to the practices by explaining the way that the surgery works as opposed to the pharmacy, so improving inter-professional working.â€
One area where she has been able to help is to encourage pharmacies to pass on patientsâ€™ requests for prescriptions in a consolidated, daily fashion rather than piecemeal. How did she get into general practice? â€œI was at a primary care integration event, bringing all elements of primary care together. A practice manager said they had advertised for a practice pharmacist and nobody had applied. I said I had been looking for a job in a practice for about three months and I couldnâ€™t find any. So I got invited for a job at the practice on a part-time basis.â€
Laura found at the integration meeting that there was uncertainty among doctors about how to go about taking on a local pharmacist to work with them on prescribing issues. â€œThey thought they would have to have several pharmacists in the practice to cover all the pharmacies that patients might use in the area. I said that all they needed was a single pharmacist with the knowledge required. That pharmacist should not be biased towards one pharmacy or another.â€
For the practices, Laura carries out medication reviews and deals with medicines queries from doctors, patients and pharmacies. She has reorganised the prescribing system in one. She also runs a respiratory and hypertension clinic in one of the practices, where she prescribes for patients. She has had previous experience of respiratory issues, having taken part in a lung-health service in Doncaster aimed at detecting COPD, emphysema and lung cancer at an early stage.
Under the service, pharmacies referred patients directly for X-ray to Doncaster Royal Infirmary. How do the doctors feel about her prescribing? â€œBoth practices are forward-thinking, which is why they were looking for a pharmacist.â€ Why arenâ€™t there more GPs like them? â€œThe problem is that most GPs donâ€™t know what pharmacists are and what we do. They are in one building and pharmacists are in another. We need to integrate more and I am working on that.â€
The DH seems to want to parachute practice pharmacists directly into doctorsâ€™ surgeries. Does she feel the way she is operating with a foot in both camps is the best way forward? â€œPractice pharmacists need to understand what is happening in community pharmacy, with stock shortages, changes to the Drug Tariff and local services and be able to feed that back into the practice. If you were just in the practice you would be isolated and be out of touch and therefore weaken the link and lose the advantage you have of seeing both pictures.â€
Does she feel she is disadvantaging other community pharmacists by being a practice pharmacist? â€œNo. I have actually had a â€˜thank youâ€™ card from one of the local pharmacies saying that, since I moved into the practice, communication has massively improved. I act like a bridge between the two.â€
How does she feel about the remuneration cut imposed by the DH and, in particular, the letter from Philip Hammond, the Chancellor, seeing pharmacy as simply a retail distribution system? â€œI think it is very wrong. Someone is advising the government and the NHS about the wrong things. To actually remove a community pharmacy from a community and put things in hubs on motorways so people canâ€™t come and talk would be to rip part of the community out.â€
Pharmacies provide an important community function as well as serving a healthcare purpose. Laura adds: â€œI have about 10 or 12 people who come in nearly every Saturday to talk to me. I might be the only person they have spoken to that week and during the conversation I might be able to pick up an early indication that something is wrong and help.
â€œWe are not supermarkets. There is the care element. We are like the GPsâ€™ surgery. You wouldnâ€™t say we are going to get rid of all the local GPsâ€™ surgeries and send everyone to a building in the middle of town. They are not going to do that because the elderly people canâ€™t get there. You canâ€™t just disadvantage the mostÂ vulnerable within our communities. â€œIf you lose community pharmacies because of sending medicines through the post, via the internet, or picking them up at a local supermarket or wherever, the 8 per cent of people in A&Es who could be dealt with in pharmacies will more than double. It will increase pressure and cost to the NHS.â€
Does she feel the Government is being badly advised? â€œAs you go up the ladder, you become out of touch with what is happening at ground level. By expanding the services that we provide and upskilling the pharmacy team we could save the NHS money. We could deal with minor ailments and medicines management, freeing up appointments at GPs for chronic and complex conditions.â€
In short, Laura feels that the DH is out of touch. But things are not all bad. Access to summary care records is seen as a positive development by Laura. â€œSCRs are particularly helpful at weekends. When a patient asks for an emergency supply, or is expecting a prescription that has not come, you can see what has been prescribed and when on the SCR and make a more educated decision about what to do. It has improved safety and patient care.â€
Does she feel that independents generally have a strong future? â€œIt depends. Independent pharmacists who are unwilling to change with the times will quickly disappear. But if you are prepared to progress and provide additional services and stay ahead, then, yes, we are going to survive.â€ And how do they upskill themselves? â€œHaving a clinical diploma and holding an independent prescriber qualification is very worthwhile. â€œYou can use independent prescribing to provide services. You wonâ€™t need a PGD to offer travel services, for instance. It gives you much more flexibility. â€œFor independents, it is a huge amount of work running a business and doing all this training. But you have got to do it or you become outdated.â€
Does she feel that the representative bodies in pharmacy are doing a good job? â€œThey vary. We roll over too easily sometimes. They need to stand up stronger for community pharmacy. â€œWe do provide an incredibly important service, yet the people at the top donâ€™t seem to value us. We canâ€™t be getting the message through to them. There must be some kind of link missing.â€
She acknowledges, however, that the National Pharmacy Association, has done a â€œhuge amount on standing up against the cutsâ€. So far as the Royal Pharmaceutical Society (RPS) is concerned, it is good locally with training but it is not so good nationally. â€œWhen I started as a prescriber, I felt worried that I wasnâ€™t going to be doing everything right and rang the RPS and got passed through to several different people and nobody came up with an answer. There was no-one there who could really help me. There needs to be really clear guidance for prescribers.â€
Does she fulfil any representative role for pharmacy herself? â€œUnfortunately not â€“ the requirements for a place on the LPC do not currently allow me access. However, I get contacted by them to help with local projects, including on falls prevention, minor ailments, and inhaler techniques, as well as linking with other local NHS services, including the drug and alcohol team.â€
Laura also liaises occasionally with the CCG, following the design of a successful emergency asthma kit for local schools. The kit contained a salbutamol inhaler, spacers and guidance for teachers on how to use the inhaler in an emergency.