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GPs' view of community pharmacy


									                         GPs’ view of community pharmacy

20 years ago I was sent as a medical student to a local training practice. It was my
first experience of what general practice was like but looking back now there are only
2 memories that stick in my mind. One was the fact that one of the GP partners had
just taken delivery of a new Morgan car, and was proudly driving around on his home
visits. Sadly it was one of my fellow students who got to join in him on his visits!

The other thing I remember very well was the relationship between the doctors and
their neighbouring pharmacist. It seemed that every coffee time he would turn up for
a chat with the doctors, and at the end of the week he came in to the room with a little
trophy. It was in the days of hand written scripts and throughout the week the
pharmacist had kept a record of any errors that had been made in writing the scripts.
That week he came with a cup and awarded it to the GP who had made the least
mistakes on their scripts.

The strength of that relationship between GP and pharmacist has stuck with me more
than any other clinical event that took place in those short weeks of my medical
school attachment in the practice. It was clear that they got on well personally, but
the professional relationship also brought great benefits. Questions were asked,
decisions discussed, and mistakes could be rectified in a spirit of mutual support and
professional colleagueship. GP and pharmacist worked together for the benefit of the
patient, and they very much appeared to be part of the same team.

20 year later, at times it seems the Government is trying to pit GP against pharmacist
rather than encouraging joint working. With an agenda of competition between
providers and an increased role for the private sector, Government policy could
potentially undo years of co-operation and goodwill between pharmacy and practice.
Both could be competing for the same work, with primary care organisations
awarding contracts to the lowest bidder.

The Government believes GPs are over paid and much of the care delivered by GPs
could be done elsewhere and in a cheaper way. Increasingly they see pharmacists
situated on the high street or in supermarkets as being a solution to this problem, and
they would not be averse to an increased clinical role for pharmacists. With an
increased number of items becoming available over the counter and with the
development of pharmacists with special interests who may have far greater access to
prescription only items, it is quite likely that the current fairly clear boundaries
between GP and pharmacist will become much more blurred in the future.

So what do GPs feel about this current agenda and how are they likely to respond?
Are we likely to see greater competition and conflict between are 2 professions, or is
there a future for co-operation and mutual gain, not just for GPs and pharmacists, but
most importantly for the patients we both serve.

GPs views of community pharmacists will be coloured primarily by the relationship
between them and their nearest pharmacy. For many this may be in the same
building, and the relationship then is likely to be strong. Seeing an individual on a
regular basis, allowing questions to be asked and discussions to be engaged in, in
person rather than other the phone, makes a huge difference to the strength of the
relationship. GPs are concerned when pharmacies seem to be staffed by an ever
changing number of locums, making it hard to build up any sort of relationship. It is
so much easier when a GP realises that the patient who has just walked out of the door
with the wrong script in their hand, to ring up the pharmacist next door or over the
road and speak immediately to someone they know, and have the confidence that the
error will be corrected before the medication is dispensed. This works the other way
too and a pharmacist who is known to the practice is much more likely to be put
directly through to the GP when necessary to raise a concern about the prescription
being provided.

However relationships are not always harmonious. Sometimes this may be because of
poor standards set by either practice or pharmacy, and at other times it is because of
poor understanding of each others role or contract. I’ve known a situation where only
one local pharmacist could read a GP’s handwriting well enough to be able to
dispense the scripts safely, and of other situations where it is very difficult for a
pharmacist to get past the surgery answer phone when it was necessary to speak to
someone in the practice. Equally GPs are concerned when pharmacists don’t give the
full amount of medication prescribed to patients, giving them instead IOUs for the
remaining amount or items. Some pharmacists appear to lose a lot more scripts than
others, or are more interested in selling patients products that many GPs would regard
as having little or no clinical value. GPs also worry about how confidential
consultations over the counter are in some pharmacies.

Patients are quick to tell either party when the other is not performing as well as they
should and maybe we should listen more to these concerns and take appropriate action
rather than reluctantly accepting poorer standards than we would hope for.

A better understanding of the different types of contracts practices and pharmacies
hold would also help to improve some relationships. Following the changes to the GP
contract in 2003, the contract for GPs is now between practice and PCO not with
individual doctors. This has led to a significant change in skill mix within practices,
and allows for professionals other than GPs, including practice managers and
pharmacists to become partners. The new contract also saw the introduction of the
Quality and Outcomes Framework, a series of targets largely related to chronic
disease management. Some of the QoF targets also encourage practices to do
medication reviews and medication audits, often at the suggestion of the local PCO
prescribing advisor.

Whilst the QoF is often regarded by the lay press as being a large financial reward for
GPs, the reality is that it was designed both to support the core work of the practice as
well as provide incentives to improve the quality of care. At the time it was
anticipated practices would be keen to engage others, particularly pharmacists, to help
them achieve the QoF targets. However practices largely re-arranged their own
systems and found they could achieve the targets set as a result, which left offers of
help from pharmacists not accepted.

GPs too don’t fully understand the new pharmacy contract. They have been frustrated
at the failure to resolve the problem of 7 day scripts requested to support monitored
dose systems, and they fail to see the value of medication use reviews, especially
when large batches of unscanable sheets arrive in the practice without any clear
indication about what should be done with them or what benefit they offer.

Clearly as GPs and pharmacists adjust to the rapid changes taking place in primary
care there is a risk that conflicts could increase as both groups compete for the same
contracts. However with better understanding of what each profession offers there is
scope for far greater joint working. Practices getting involved in practice based
commissioning will have greater incentive to prescribe cost effectively and many are
already engaging community pharmacists to help them develop practice formularies
or make significant prescribing changes. Agreeing how medication use reviews can
be done that both improves patients’ use of medication and cuts costs will also see
greater support from practice based commissioners. As GPs develop a greater role in
supporting movement of services from hospital in to the community, working with
pharmacists to, for example, increase near patient testing or increasing minor ailment
schemes may be appropriate.

Practices looking to expand their premises can often only do so with the co-operation
of a pharmacy, developing both in the same building. In these situations it is much
more likely that GPs and pharmacists will enter partnership agreements with each
other, although in the case of larger premises developments it may be that the large
pharmacy chains may see the direct employment of GPs as an option, although past
experience with dentistry may make some more cautious about this.

And as the current political agenda for extended hours progresses, practices will want
to work with pharmacies to try and support better access arrangements to suit their
particular population. Electronic prescribing, access to a summary record and repeat
dispensing will also transform the way pharmacists can be more directly involved in
individual patient care, and will bring further opportunities for greater working
between GP and pharmacist.

Whilst a culture of competition may be what some in government want to see
develop, GPs and pharmacists can only gain by closer co-operation and better
understanding of each others skills and areas of expertise, with the result that patients
will be better served by both.

Richard Vautrey
Deputy Chair GPC


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