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A pharmacy with a difference

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A pharmacy with a difference

The winner of the Pharmacy Team Learning and Development Award in the IndependentPharmacy Awards for 2016 was Paul Scott-Harris of the Buxted Pharmacy. Douglas Simpson went to East Sussex to find out more about Paul and the pharmacy in which he practises

Paul Scott-Harris graduated in pharmacy from Brighton school of pharmacy in 2008. It was his second degree, having earlier graduated in applied biology from Kingston University. His first experience of working in a pharmacy was a two-week placement with Boots, aged 16, while still at school. That led to more work with Boots.

Although Paul enjoyed the work, it did not inspire him to want to become a pharmacist. The focus was very much on throughput of prescription items and OTC sales. There were no services. So Paul embarked on the applied biology course at Kingston. He did not leave pharmacy completely behind, since he worked for both Boots and Lloyds Pharmacy while an undergraduate, becoming a dispenser in the process.

Next came laboratory work for GSK. He decided that was not for him either: “I missed people interaction and I knew pharmacy, so I went back and enrolled to do a pharmacy degree at Brighton.” After graduation, pre-registration was with Day Lewis in Hastings. Then it was back to Boots for a bit before taking a job in a private hospital – second pharmacist at the Nuffield Hospital in Tunbridge Wells. He was then asked to work for Spire Hospitals at Gatwick as head of the pharmacy department.

Working in private hospital pharmacy, Paul found that although the patients were coming in for elective surgery, they still had the same issues you would find in the community. “We had to make sure their medications were right and to help ensure their stay in hospital was as effective as possible,” he recalls.

With limited prospect of further progress in private hospital pharmacy, it was back to community pharmacy again, with the Co-operative Pharmacy at Peacehaven. Then David Wright, senior partner of the GP practice in the Medical Centre in Buxted, East Sussex, asked him to become the managing pharmacist at the pharmacy owned by the doctors in the centre. Paul lives in the village and knew Dr Wright at the time of the invitation, so was happy to accept. He took up post in January 2013. He is the second manager of the pharmacy since its inception.

The medical centre
On entering the purpose-built medical centre, a large central lobby is visible, with chairs for waiting patients. To the left is a reception desk for the medical practice of eight doctors. To the right is the pharmacy, clearly labelled Buxted Pharmacy. It has its own consulting room.

The practice is a rural one and, as well as the pharmacy, there is a GP dispensary for the practice’s dispensing patients. There is open access between the pharmacy and the dispensary, and to the casual eye they would seem to be part of the same unit. But the dispensary is managed separately (although Paul helps with dispensary staff training).

The pharmacy sells medicines, as well as dispensing prescriptions and providing pharmacy services. The inventory is, however, limited by a restrictive covenant applied by the owners of the land on which the property is built. The land was gifted by a local benefactor, Basil Ionides, and is operated by a trust. The trustees do not allow any retail sales to take place, so no GSL medicines can be made available nor any other goods that might be sold in a pharmacy. Pharmacy sales are restricted to P medicines.

Paul says: “Being only able to sell P line medicines makes my job rather difficult. Otrivine nasal spray, for example, is very effective but I can’t sell it because it is GSL. There is nowhere else in the village where people can buy such medicines.” He has tried appealing to the trustees to allow sales of GSL medicines, but has so far been unsuccessful. “But I have not given up trying,” he says. There is, however, one other thing that could help, and that is for the local CCG (High Weald Lewes Havens) to introduce a minor ailments scheme.

“We could supply a GSL as part of a service even though we could not supply it as a retail selling operation,” Paul says. As yet, the CCG has not introduced such a scheme, although next door at Hastings and Rother CCG, one is currently under trial.

How does Paul find operating a pharmacy alongside a doctors’ dispensary? “It is quite difficult for patients to understand the difference in the services provided by each,” he says. How does working for a doctor-owned pharmacy affect what he does? “The agenda is not all about the number of prescription items. For me, it is about rationalisation of medicines use – pure medicines optimisation. We have quite a low amount of returned medicines wastage in the pharmacy.”

What kind of responsibilities does he have that he would not have in an ordinary pharmacy? “I am the superintendent pharmacist here,” says Paul. “That is different to a normal pharmacy manager’s responsibility.”

What can he do that would not be done in the average pharmacy? “High street pharmacies have their own agendas and, as we are owned by the GPs, we share the same agenda,” Paul explains. “Being within the surgery helps with communication as I can directly message a GP with a query or concern and normally receive a reply in moments.

“We also have read-write access to patients’ records, so we can see what is going on with patient medications – what has been stopped and what has been started; whether it is a GP choice, a consultant instruction or a discharge medicine from hospital.

“This really helps with understanding the rationale behind the use of medicines, especially where there is unlicensed use.”

Access to records is part and parcel of the pharmacy being owned by the GPs and is possible because Paul has a second employment contract with the surgery as well as the pharmacy. Outlining how he makes use of this facility, Paul says: “A good example would be when I perform MURs. The national MUR template surrounds compliance and concordance – whether a patient can take a medicine, whether they are still taking it. DRUM reviews performed by dispensing doctor staff are not very dissimilar to the MUR. But because I have access to records, I can go into things in more depth.

“A lady this morning had problems with sleeping, and I discovered she was suffering with low mood. Following NICE guidelines, she had not had a discussion with a GP, and therefore not been offered CBT. I am picking up that kind of thing and I am able to take it up with her GP. It may be a change to her therapy, but it helps to see what has been discussed before.

“And if I think something needs to be picked up, I can book the patient a slot to discuss the issue with their GP. A good example includes outcomes from clinical MURs, such as bloods that may be required, medicines that may need changing following new guidelines, etc. Therefore, there are actions from the reviews performed.”

Paul compares this with the fate of MURs elsewhere: “They are fed to surgeries where it is up to the administrative staff to forward them to GPs. A lot of them are just ignored.” He does not currently have any special roles, such as looking after patients with long-term conditions, but he is enrolling at the University of Brighton to do an independent prescriber course.

“A GP at the surgery will act as supervisor,” says Paul. “My aim is to manage hypertension.”

Are there any lessons that community pharmacy generally could learn from the way he operates in the Buxted Pharmacy? “I have been told that we are working around four years ahead of community pharmacy, with our read-write access to patient records. I understand this to be the next stage for pharmacists through the summary care records (SCRs).”

Experience at the pharmacy is being used to inform the next generation of pharmacists. Undergraduates from the University of Brighton have placements there. “Our unique selling point is that we are in a GPs’ surgery so they get to see how this works too.”

The pharmacy provides a wide range of services. As well as MURs, these include NMS, EHC, flu vaccinations, smoking cessation, c-card and chlamydia test kits. Also on offer is the Lipotrim weight management programme. Blood pressures are routinely performed for the surgery and all team members are able to do this. The pharmacy is also involved in clinical trials. The next one due is for Dymista, a nasal spray for allergic rhinitis.

Staff numbers in the pharmacy are nine. There are two pharmacists – Paul working four days (8am to 6.30pm) and a regular locum who works for one day. (The medical centre is not open at weekends so the pharmacy cannot open.) Other staff include an accredited checking technician, a dispensary assistant, a pre-registration pharmacist, two medicines counter assistants and two drivers.

The Independent Pharmacy Award was for pharmacy team learning and development. How has the team developed over the years?

“Really well,” says Paul. “It all starts with recruitment. When I hire people, I look for good attitude and behaviour. I generally don’t hire on knowledge or skill because that can be trained. You can’t train attitude or behaviour.”

All team members have undergone medicines counter assistant training to improve their skills in dealing with patients. They are also able to perform each other’s roles and duties, and they all lead on a specific lifestyle service, which “increases service availability, team engagement and ownership”.

“Weekly huddles” are used to discuss good and bad points from the previous week, and to recognise successes as well as identifying learning opportunities. A training matrix is used to chart all team members’ progress and development.

Counter staff use a COPD6 machine to aid diagnosis and screen patients for COPD while they’re waiting for their prescriptions.

Three staff have been trained as healthy living champions in preparation for the pharmacy acquiring HLP status.

If Paul can’t provide the training himself, he uses external providers. “I use the NPA a lot,” he says. “I am very impressed with their quality. Their courses give staff the depth and breadth they need to allow work to be delegated to them.”

Further development
As for developing the business further, Paul has plans. “Being an independent prescriber will aid progress,” he says. “I am also keen to develop new services. We are in a good position to test other services as they are coming through. I have made an offer to the CCG to do that, but it is not willing at the moment.”

Paul does have some experience of this. “We participated in a dementia pilot with the CCG. Each patient was assessed by a nurse and also by me,” he explains. “I did a complete review of all their medications, including the muscarinic burden, and whether there were alternative medicines they could have. I performed this on top of my daily workload, which stretched the team. A third person performed a social assessment of the patient. Once all these assessments had been done, each patient was seen by a GP, who would then form a plan for the patient.”

The pilot was extremely successful and a CCG-wide protocol has been rolled out, looking to be national. The irony is that Paul will not be part of it.

“My understanding is that the CCG does not seem to trust community pharmacists to be able to help with this,” he says. “The CCG is investing in pharmacists in surgeries instead. Pharmacist placements will be funded centrally through the CCGs and their roles would not just be about the dementia pilot, it is medicines optimisation as well. The CCG is trying to cover many bases with the same person.

“To me, it seems crazy to provide more pharmacist positions, rather than empower the community pharmacist network already in post.”

Paul continues: “It seems to be about control as well as the current pharmacy contract. How can you give someone permission to change patient medications when the contract is based on prescription item numbers? There has been evidence that services (MURs) have been financially rather than clinically driven or based on need, so you can understand a government’s position. Furthermore, pharmacists do not routinely attend multidisciplinary team meetings. It’s our fault as the missing professionals at the table.”

Paul does not expect things to get better any time soon. “As far as independents are concerned,” he says, “the 12 per cent funding cut is going to erode their numbers. The ability to work differently and trial things will be correspondingly diminished. It’s going to be all about the big corporates again influencing pharmacy. They have larger prescription numbers and so a larger say.”

There is no doubt about where Paul sees the future for independents: “Let the multiples do hub and spoke and go for the stock purchase margins. For the pharmacists on the ground who want to influence their patients and try different systems or procedures then it should be the independents who do that. We should be empowered to do that and not stopped.”

Paul has ideas for how this could be achieved. “Why don’t you reward pharmacists for how many unnecessary medicines they stop with a patient?” he suggests. “That would get pharmacists paid for using their clinical skills. That would be a win for the patient, for the pharmacist and the GP.”

No effective voice
When asked how he feels about progress of community pharmacy generally, Paul says: “Lots of pharmacists are disillusioned with what is going on. A lot of things are done to pharmacists because we do not have a single effective voice. We desperately need to have a single lobbying voice, such as with nurses and doctors. Half of that is our own fault as we have allowed big companies to make decisions and be our spokespersons. I think, too, that we are suffering with an identity crisis – whether we are simply about process or whether there is a clinical constituent to our role and what that level can or should be. Working alongside a GP dispensary is an eye opener but all this does, for me, is reinforce how the government sees pharmacy – ‘a process that could do with a price reduction’. We need to lobby for cost-effective clinical services at the point of need to support nurses and GPs. I can see my value to my patients, but I’m only one voice”.

“There is much more that we can do. I think we are in an ideal position at the moment as there are not enough GPs and many in the next 10 or 15 years will be retiring, while there is a glut of pharmacists. We can help fill the gap, certainly within our pharmacy. The doctors here reckon that I could do 40 per cent of what they do.”

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