Optimising the pharmacy team to deliver effective medicines reconciliation during new patient registration

Within the primary care pharmacy team, pharmacists and pharmacy technicians work closely together, with each member playing a distinct yet complementary role. As clinical and medicines experts, pharmacists are primarily responsible for clinical decision making, medication review and patient consultation​[1]​. Pharmacy technicians have a crucial role, focusing on the operational aspects of medication management, such as medication reconciliation and prescription queries​[2]​. They also enhance the delivery of safe, effective and efficient medication systems using their complementary skill sets and expertise​[3,4]​. Together, pharmacists and pharmacy technicians enhance the overall efficiency and effectiveness of medication management processes. Furthermore, pharmacy technicians play a crucial role in supporting the Care Quality Commission’s primary lines of enquiry, particularly in areas such as medicines reconciliation and therapeutic drug monitoring​[5]​. Through their efforts, they ensure that patients receive safe and appropriate medication therapy, while also addressing regulatory requirements and quality standards. 

This article considers how the reconciliation skills of a clinical pharmacy technician can be used during new GP patient registrations to support safe medicines use.

How pharmacy technicians can help with the registration of new patients

Medication issues and errors are well documented when patients transfer between care settings. In 2012, a report led to the introduction of formal medicines reconciliation for most hospital admissions​[6]​. Medicines reconciliation is often undertaken by pharmacy technicians. 

In primary care, additional roles funding was extended to pharmacy technicians in 2020, which led to an increase in the number of technicians working in primary care networks and GP surgeries. The number increased by 40% between December 2022 and December 2023, from 1,633 to 2,292​[7]​. As registered professionals, pharmacy technicians have good medicines knowledge, excellent attention to detail and communication skills, which ensures that medications are updated on primary care GP systems accurately following a hospital admission. 

New patients joining a GP surgery have not traditionally received reconciliation, with medication lists either being imported directly across from the previous GP surgery (if their computer system is compatible) or being added by a GP or nurse practitioner during a new patient appointment. This can be problematic if the patient has joined the surgery from overseas with little information about blood tests and monitoring available. The new patient registration is another ‘interface’, where medication omissions and errors can potentially occur. Having a pharmacy technician reconcile the medicines at this point can lead to improved medicines safety and reduce the workload for GPs and nurse practitioners.

Four clinical scenarios that require professional judgement are discussed below. The clinical pharmacy technician should work within their scope of practice and discuss more complex patients with the clinical pharmacist or their designated lead GP. The purpose of these scenarios is to foster reflection, acknowledging the diverse factors influencing individual practice. These examples are drawn from real cases dealt with by a pharmacy technician, with details altered to preserve confidentiality. 

Scenario 1: A heart transplant patient

A new patient arrives at the GP surgery asking for his medication. He has moved from another area of the UK and had a heart transplant while living there. As well as regular cardiac medications, he is taking two immunosuppressants that are classed as hospital-only medications, and states he is due blood tests to check levels of these medications.

Questions to ask

The first question the pharmacy technician should ask is how much medication the patient still has left and when they will run out. Having clarified this, some details about their current provider and any link nurse numbers should be obtained. Although these nurses will no longer be able to supply medication via their homecare system once the patient has left their area, they will often provide advice and blood level interpretation while an urgent referral is made to the new homecare provider.

Things to consider

Pharmacy technicians should be aware of ‘red’ hospital-only medications on the formulary and when to highlight patients urgently for a pharmacist review. In this scenario, the GP may need to prescribe ‘red’ hospital-only medications for a short period until the new provider takes over care, as there is no alternative. The technician or pharmacist may wish to discuss this with the local integrated care board’s medicines management pharmacist/technician, as they will see this prescribing on the surgery ePACT data.

Reflections and best practice

This scenario demonstrates the issues that can occur when patients move to another area of the UK and the need for an efficient transition between settings. The pharmacy technician would need to highlight this patient urgently to their pharmacist/GP lead for a review as well as contacting the previous provider’s nursing team in order to safeguard the patient from missing medications or incorrect medication levels if the blood tests are abnormal.  The technician can act as a liaison point within the surgery for the previous care provider, as well as the new provider once the referral has been sent.

Scenario 2: a patient with rheumatoid arthritis

A patient aged 73 years from overseas registers at the surgery. She has several medical conditions, including rheumatoid arthritis, for which she is currently taking methotrexate 15mg tablets. She informs the pharmacy technician that methotrexate is managed solely by the GP in their home country and only one blood test per year was required, which they are keen to continue. 

Questions to ask

The pharmacy technician should ask if she has brought any GP notes from overseas and check when her latest blood test was taken, because it could have been several months ago. If it was longer than three months ago, tests should be arranged to check her full blood count, liver function and C-reactive protein, urea and electrolyte levels.

Things to consider

Rheumatoid arthritis and methotrexate are managed as shared-care medications in most areas of the UK. The pharmacy technician should be aware of local shared-care guidelines and which medications are subject to regular blood monitoring. 

The technician would need to advise the patient of the local prescribing/monitoring arrangements for methotrexate and that the GP will do a referral. If the patient declines to see a local rheumatologist, the technician will need to explain that the GP may not be happy to prescribe if there is no shared care in place with a consultant. 

Reflections and best practice

This scenario demonstrates the need for the pharmacy technician or pharmacist to be able to educate patients on local arrangements, building trust with the patient but also managing expectations. Patients who join GP surgeries from overseas may be used to different systems of medical provision, and the pharmacy technician can be a good resource for these patients in explaining how local healthcare systems work.

Scenario 3: A new UK arrival with diabetes mellitus

A new patient and her daughter, aged 11 years, arrive at the GP surgery to register. They are refugees from abroad. An aunt who speaks some English arrives with them, but the patient and her daughter speak very little English. The aunt explains that the girl is a type 1 diabetic. The mother shows that her daughter is wearing an insulin pump and indicates she needs more insulin, pump lines and cartridges, Dexcom G6 sensors and testing strips.

Questions to ask

The first question the pharmacy technician should ask is how many days of insulin pump lines and sensors the patient has left. Insulin pump lines and cartridges need changing every 2–3 days, depending on the type, and sensors every 10–14 days. The pharmacy technician should be able to arrange a prescription for the insulin for her to fill her cartridges and testing strips, if these are available locally, or arrange a swap to a formulary testing meter if needed.

Document the name of the pump and the type of lines and sensor used to be able to hand this over to the hospital. Insulin pump cartridges and lines are not prescribable on FP10 and are supplied through a homecare system, which is usually set up by a consultant-led team at the acute trust.

Things to consider

People with type 1 diabetes mellitus are completely dependent on insulin and require access to some form of testing or monitoring device at all times, especially when calculating insulin doses to cover meals. Failure to administer enough insulin could lead to the patient developing diabetic ketoacidosis, which can be fatal.

The pharmacy technician should highlight this patient urgently for a review by the pharmacist or GP and ask for an urgent referral to the acute trust paediatric diabetologist. The pharmacist/technician would need to speak to the paediatric diabetic liaison nurse if supplies of lines and cartridges are running low. Inform the hospital which language she prefers to speak so that they can arrange an appropriate translator when she is seen in the clinic.

Reflections and best practice

This scenario highlights that language barriers can be high when patients first arrive from overseas, but that the pharmacy technician should be able to manage this, using the surgery translation service where necessary. They should also use their medicines management skills to identify the need for urgent medication/medical supplies and the substantial risk to the patient if this is not actioned in a timely manner.

Scenario 4: A teenager with ADHD

A family joins the surgery from another surgery, and the pharmacy team undertakes new patient checks with the mother and her teenage son. The family moved to the UK from overseas three years ago. The mother explains that her son was diagnosed with ADHD by a psychiatrist in their country of origin when he was aged eight years. He has not had any specialist reviews or dose changes since coming to the UK. He is currently taking Concerta XL (methylphenidate hydrochloride; Janssen-Cilag). 

Questions to ask

The pharmacy technician should check the medication that the patient is taking and ask for copies of any assessments and paperwork from the overseas psychiatrist. They should arrange for the height, weight, blood pressure and pulse to be checked by the healthcare assistant or through self-monitoring, if available, and add these to the notes.

Things to consider

ADHD medication is usually supplied under a shared-care agreement and there is clear guidance from the National Institute for Health and Care Excellence regarding the physical observations that are required and the need for an annual review by a specialist. This patient should be highlighted to the clinical pharmacist or prescribing lead GP for review.

The pharmacy team needs to explain that this medication requires specialist review and discuss ways that this can occur. There is often a long waiting list to see child psychiatrists on the NHS, so the quickest way for this child to be reviewed would be through a private provider who specialises in ADHD.

Reflections and best practice

Highlight this child to the registering GP and explain the situation. The GP may be unwilling to continue the medication until the child sees a specialist. You should ask the GP to refer the patient to an NHS child psychiatrist, even if the mother chooses to see a private psychiatrist in the meantime.

Conclusion 

Screening new patients with complex medication and medical histories requires diligent assessment and coordination to minimise risk. Each scenario presented in this article highlights the importance of timely referrals, communication with specialists, checking observations and adherence to guidelines for medication management. The clinical pharmacy technician is ideally placed to deliver this, promoting better health outcomes and safer medicine management.