There are 32 GP practices in Newcastle upon Tyne that have the same challenges and concerns that are being experienced nationwide: patient contacts are increasing in number and complexity, while it is becoming more difficult to recruit and retain staff, especially GPs.
In 2017, our place-based team identified GP workload associated with prescriptions, transfers of care and associated administrative duties as a priority for transformation. At the same time, the local NHS trust (an acute and integrated care provider) was seeking to improve clinical pharmacy provision to GP practices and local people in primary care, with a view to preventing admissions and improving health outcomes. These mutual priorities gave us a reason to collaborate and we were fortunate that leaders from all the organisations involved came forward to do so, giving us high-trust relationships and momentum.
After months of stakeholder engagement and planning, our integrated pharmacy hub opened in September 2018 with six partner GP practices, with a total of around 60,000 registered patients. GP practices that did not join us at the beginning said that barriers included financial cost and uncertainty that pharmacy could deliver their aims.
The enablers for the project were the NHS trust agreeing to hold employment risk and provide the service ‘at cost’; co-design of aims and standard operating procedures (SOPs); activity mapping in the partner practices, a short, three-month get-out clause for all organisations; project management support; and a financial subsidy of a 12-month proof of concept pilot by the place-based team.
The service’s unique selling point is our access to both primary care and hospital records, including hospital clinical notes, disease-modifying anti-rheumatic drug (DMARD) and anticoagulant monitoring, and dispensing records. We have not experienced recruitment problems to our pharmacy team, which we believe is because we are a large NHS trust offering clinical supervision and support, all essential medicines information resources and several non-pay benefits.
From day one, our primary aims have been to improve the safety and efficiency of transfers of care for Newcastle’s population, and to get our GPs “home in time for Love Island“. Over the first 12 months, the integrated pharmacy hub saved GPs between 45 and 120 minutes of time each day in our partner practices. That equates to more than 1,500 extra appointments per GP, per year.
Using quality improvement approaches, we have expanded the scope of the service in each subsequent year, now taking work that GPs were initially reluctant to delegate. Examples of this include managing acute flares in long-term conditions, such as eczema or COPD. We can and do give real-time feedback to our colleagues in the acute trust, enabling learning from poor transfers of care and teaching clinicians how to access primary care records correctly.
We have also influenced changes to prescribing policy, content of discharge letters and electronic transfer of care procedure in the acute trust using a systems-based approach to risk management. The service has expanded because of word-of-mouth recommendations and a small amount of direct marketing to practice managers. Presently, we provide the service for more than 200,000 registered patients, with plans to expand further in the next quarter.
To date, no partner practice has decided to stop using the pharmacy hub service once they have joined. We conduct support visits and listening exercises to maintain our awareness of the needs of the practices; our work lists are held in each GP practice system so that they are visible and also so we can better align with each practice’s existing workflow and protocols.
The staffing model we employed in the proof-of-concept year was 1.0 whole-time equivalent (WTE) pharmacy technician per 19,000 registered patients plus 1.0 WTE pharmacist independent prescriber per 120,000 registered patients. The pharmacists provide supervision for the pharmacy technicians and make decisions that were outside the scope of our SOPs. We have subsequently made small reductions to the pharmacy technician ratio in the model following capacity-demand modelling and to meet NHS England requirements for the additional roles reimbursement scheme, where networks are using those funds to part cover the costs of the hub service. As a result, there are presently 1.0 WTE pharmacy technicians per 17,700 registered patients.
Our SOPs are available in the public domain on the Newcastle Hospitals website and our model has already been adopted and adapted for local context by pharmacy teams in Sunderland and Leeds.
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