Primary Care Pharmacists Association Practice Pharmacists Group Symposium 2016 10th March 2016 : The Studio, Birmingham Clinical Pharmacists in General Practice Pilot Case Study : Florence Road Surgery Ealing GP Federation Dr David Evans, Senior Partner & Dr Graham Stretch, Prescribing Lead Florence Road Surgery, Ealing, London DavidEvans2@NHS.net GrahamStretch@NHS.net @GrahamStretch

Overview Background Journey Current Service The Pilot in Ealing Florence Future Plans

Florence and Bramley Surgeries Two sites 16,000 10 GP principles 5 Nurses (1 IP) Teaching Practice: 2 GP Registrars

…if they can have clinical pharmacists, why can’t I?

2005 – struggling nursing home ↑ joint local CP / GP working 2009 Nursing home study ↓ 91% Errors Pharmacy, Nursing and Medical Press National Daily Telegraph, Scotsman Past Future

2010 – 91% Error reduction Half day ward round ‘most vulnerable : least likely to receive pharmaceutical care’ just a driver

2005 – struggling nursing home ↑ joint local CP / GP working Past 2005 – struggling nursing home ↑ joint local CP / GP working 2009 Nursing home study ↓ 91% Errors Pharmacy, Nursing and Medical Press National Daily Telegraph, Scotsman 2012 Medicines Management Sessions Future

Meds Management QIPP Management of prescribing CCG audits, targets and review work Increasing information and clinical case load Budget and targets met

Pharmacy team with full skill mix Past 2005 – struggling nursing home ↑ joint local CP / GP working 2009 Nursing home study ↓ 91% Errors Pharmacy, Nursing and Medical Press National Daily Telegraph, Scotsman 2010Medicines Management Sessions Pharmacy team with full skill mix 4 Pharmacy Techs, Pre-reg, Clinical Pharmacist, Pharmacist IP x3, Lead Management of Prescribing & Clinical Sessions Future

Protocol

Advantages Refer complex queries eg. Training for GP Registrars CQC Premature infants Trazodone titration Training for GP Registrars CQC “Excellent – very impressed with pharmacy team”

Benefits Cost effective Time effective > 95% of prescribing (Budget >£1.2m) GP Savings = 45m – 60m / day / GP (x 10 GP!) Reception Time freed up ~ ‘para-legal’ ‘PA’ to individual GP Nurse Chronic Disease Management Polypharmacy Information PATIENTS – accessible, approachable, timely

Pharmacy team with full skill mix Past 2005 – struggling nursing home ↑ joint local CP / GP working 2009 Nursing home study ↓ 91% Errors Pharmacy, Nursing and Medical Press National Daily Telegraph, Scotsman 2010Medicines Management Sessions Pharmacy team with full skill mix 4 Pharmacy Techs, Pre-reg, Clinical Pharmacist, Pharmacist IP x3, Lead Management of Prescribing & Clinical Sessions Future Full time equivalent clinical pharmacist role Triage and Treat - v Medicines Optimisation & Polypharmacy Chronic Disease Management Integrated Case Coordination Health and Social Care .

The Pilot - Ealing GP Federation 17 Practices – 131,000 population 6 Pharmacists 1 Senior Pharmacist 5 Clinical Pharmacists (WTE) 60 Sessions

KPIs At least 60-70% of pharmacist time spent in direct contact with patients – face to face or telephone A baseline of >60% of pharmacist appointments will release an equivalent GP appointment 95% of discharges or OP, medication reconciled 1/52. Readmission contact 1/52 Patients with diabetes stratified as high risk by the Out of Hospital Strategy reviewed every 6 months Patients with uncontrolled hypertension (eg >150/90) reviewed each six months Communications from other care settings reviewed within one week – current practice baseline. Satisfaction feedback from community pharmacist (closest four) All errors coded and 75% reported to NRLS online Pharmacist satisfaction measurements exceed that of practice average >60% uptake of EPS2

At Florence - development Senior pharmacist and pilot pharmacist Shadowing GP/Nurse and pharmacist Pharmacist and GP/Nurse Debrief with Clinical Supervisor Initially after each session Less frequent with experience Weekly lunch time meetings with other pilot pharmacists Weekly clinical meetings / case discussion PPG engagement

At Florence Clinics / Home visits Care Coordination Complex Elderly / Palliative Polypharmacy – Meds Optimisation – Meds Review Chronic Disease Diabetes Respiratory Cardiovascular Care Coordination Joint visits Medication review

At Florence ‘Triage and Treat’ Afternoon sessions – 2 hours call back 2 Hours face to face to treat Odyssey “The clinical assessment stage allows the doctor or nurse to perform an in-depth clinical assessment with … telephone assessment … clinicians to practice according to the most up-to-date best practice guidelines, helping them to make informed decisions and deliver a consistently high quality service for every patient” Murdoch J, Barnes R, Pooler J, et al.. BMJ Open 2014;4:e004515. doi:10.1136/bmjopen-2013- 004515

Triage Support Tool

Pharmacy Skill Mix Clinical Primary Care Prescribing Management in GP Broad Church – 8,000 meets 11,000 What does each stakeholder bring to party? Primary Care GP - Prescribing GP - Clinical Primary Care CP Tech IP CCG Prescribing Management in GP Clinical Diploma RPS Faculty

The Future Joint Projects with Community Pharmacy Training for CP Diabetes 6 Month Reviews in CP - Structured Motivational Interviewing Diet Physical Activity Medication Use (SCR) Smoking/Alcohol Flu Jab BP BMI Training for CP Communication – coordination of Bloods (HbA1c, Lipids Urine ACR, Renal)

The Future Advanced Assessment Skills for Clinical Practice LSBU Nursing School Research – PhD Student for 3 years / Post Doc Reading University Faculty – Advanced/Fellow Consultant Pharmacists – why not GPP?