Chris Roberts: ‘We’re trying to demedicalise health care’

Fleetwood, a small coastal town in Lancashire, faces high levels of deprivation and generally poor health outcomes. But in October 2018, Fleetwood Primary Care Home won ‘Primary care home of the year’ at the National Primary Care Home Awards, run by the National Association of Primary Care.

There are 
more than 200 primary care home sites in England, each of which uses integrated working between primary, secondary and social care to offer personalised and preventative care to communities of between 30,000 and 50,000 patients. The sites cover nine million patients across England in total — or 16% of the population.

Pharmacist Chris Roberts, the medicines management lead for Fleetwood Primary Care Home, which looks after around 30,000 patients, has helped his team win the ‘Primary care home of the year’ award, steering the community’s health in the right direction in the process.

What’s your job?

As well as the medicines management lead for Fleetwood Primary Care Home, I’m a pharmacist prescriber at the Broadway Medical Centre in Fleetwood. My job roles include dealing with long-term conditions, medicines management and providing training for healthcare workers. I’m also a mentor for pharmacists new to working in a GP setting.

Why did Fleetwood Primary Care Home recently win ‘Primary care home of the year’?

We have got quite a job to do here. Fleetwood is an area of high deprivation. We did have a crisis in the town a few years ago — 7 out of 16 GPs left their roles across the town’s 3 practices and we struggled to recruit more. But we were awarded £500,000 from the Prime Minister’s Challenge fund in 2015 to help improve access to GP services, and alongside that I set up Fleetwood’s minor ailments service. We put EMIS (EMIS Health; Leeds) [software that allows pharmacists access to the GP patient record] into community pharmacies so they could access patient information.

Life expectancy in the town is lower than average and there is a high incidence of all long-term conditions. We have high hospital admission rates and we are working to treat our patients better in the community, to improve their quality of life and reduce the cost to the NHS of that secondary care.

I think we won the ‘Primary care home of the year’ award because of the work involved in supporting our patients, but also we are forward-thinking — we think about different ways of managing our patients

I think we won the ‘Primary care home of the year’ award because of the work involved in supporting our patients, but also because of the way we think in Fleetwood. We are forward-thinking; we think about different ways of managing our patients. We look at social prescribing — we are not just trying to go down the route of using medicines at will. We have set up singing groups and weight-management groups, both of which have put more emphasis on patients looking after themselves, with more emphasis on prevention. And we have got Healthier Fleetwood, a resident-led partnership with healthcare providers and the wider community, which works to improve residents’ health and wellbeing. This is all part and parcel of why we won the award. There is a lot of resident involvement in Healthier Fleetwood and it follows the social prescribing model.

We have got multidisciplinary working across all the healthcare providers: the dental team, the community pharmacy team, community care, nursing, mental health and the practices. We take a holistic approach to health needs and work in an integrated way.

We became a primary care home in April 2017 but we have been working in this way for four years.

When Fleetwood was short of GPs, did you find yourself under increased pressure as a pharmacist to fill the gap?

Until 2016 I was operating Warburton’s Chemist, a community pharmacy in the town, but we had links with GP surgeries and I worked with them giving medicines management advice. I had done a prescribing course a year or two before and, because of the GP shortage, I felt it was more beneficial for me to go into one practice and become part of their multidisciplinary team to pick up some of the slack.

Having a clinical pharmacist in a full GP surgery role was pretty revolutionary at the time. I approached a practice that was two GPs down and said: “Do you want to employ me? I will help with medicines management, reviews, long-term conditions, with patients being discharged from hospital.” So yes, there was an impact on pharmacists, but we were also part of the solution.

Areas of deprivation tend to have more community pharmacies than more affluent areas. How do patients view pharmacists in your area — do they trust your advice?

I think pharmacists are generally trusted. Patients possibly do not come to pharmacies first, though, because of the deprivation and the fact that they would have to pay for some medicines. The minor ailments scheme has been pulled, unfortunately, because of its cost.

On the whole, pharmacists are well-respected as the first port of call for health information and are seen as experts. People feel we have more time to speak to them than doctors do.

I do sometimes feel that the pharmacies are very busy because of the healthcare needs in the town.

What particular health challenges does Fleetwood face and how are pharmacists helping with those?

We have a high level of drug and alcohol misuse in the town. Inspire, a drug and alcohol service, has a close link between the GP surgeries and the community pharmacies that deliver medicines to Inspire’s service users. There are also programmes focusing on obesity management and stroke prevention, and identifying people with hypertension.

Identifying pre-diabetics in community pharmacies, GP surgeries, and even within dental surgeries, means we can stop that progression

At the moment we have got a push to try to find out who is at risk of diabetes. Identifying people with pre-diabetes in community pharmacies, GP surgeries, and even within dental surgeries, means we can stop that progression. Community pharmacists can advise current patients with long-term conditions through their medicines use reviews and new medicine service, making sure that they take medicines properly.

We are starting a chronic obstructive pulmonary disease (COPD) project with Fylde and Wyre clinical commissioning group, GP surgeries, community pharmacy and with support from the pharmaceutical industry, to raise awareness of COPD and screen at-risk groups of patients. We will be reviewing and medically optimising all COPD patients according to local and national guidance, and trying to improve the uptake of pulmonary rehabilitation; smoking cessation; and influenza and pneumoccocal vaccines.

One of the main things that Healthier Fleetwood and the Primary Care Home are trying to do is demedicalise healthcare and get services back on the high street. Patients go to community pharmacy to get their prescriptions once per month, so pharmacy is well-placed to do preventative work whereas patients might not see a GP until they are already unwell.

In general, it is just about pharmacy having conversations with GP surgeries. Talking to GPs can be tough because they are very busy; sometimes the relationship is strained. We need to change that and have positive, proactive conversations about what community pharmacy can offer to general practice. I think there can be a bit of doubt from community pharmacy about what they can offer — do they have the correct skill mix? Pharmacists may feel that they have deskilled themselves because of the volume of prescriptions they are processing, but they may just need reminding that they do have clinical skills.

Do you have any messages for policymakers about how they can help you improve the health of residents in areas like Fleetwood?

Keep the funding coming — it is about putting money into areas of deprivation. For example, mental health is a very significant issue in Fleetwood — we have a high prevalence of mental illness in adults and children, and it is an issue that has been highlighted by residents as a priority. An award-winning primary care-based mental health service has been available in the town since 2004, but we could do a lot more if more funding was available.

Fleetwood is a small town of 30,000 people, so it is an area where we can deliver at quite a pace — but the funding stream seems to be quite slow

We have carried out lots of healthcare pilots here and we need to keep doing that. We like to do things quickly in Fleetwood — it is a small town of 30,000 people, so it is an area where we can deliver at quite a pace. But the funding stream seems to be quite slow; it takes too long.

Mark Spencer, the GP who leads Fleetwood Primary Care Home, has said that there needs to be a genuine national imperative to address health inequalities by increasing funding to areas with the worst health outcomes. Clinical commissioning groups in certain areas get a given amount of funding per head of population, but that does not equate to the inequalities, unfortunately.