The new community pharmacy think-tank

Neighbours from hell or a match made in heaven? The C+D Senate unpicks the pharmacist-GP relationship and identifies how the warring sides can put their differences aside for all patients’ benefit. Zoe Smeaton reports

The Senators

Graeme Betts
Director of region, Lloydspharmacy

Alastair Buxton
Head of NHS services, PSNC

Michael Cann
Chairman, British Generic Manufacturers Association

Max Gosney
News editor, C+D

Martyn Lobley
GP, south east London

Fin McCaul
Chair, Independent Pharmacy Federation

Gary Paragpuri
Editor, C+D

Hiten Patel
Managing director, Pharma Plus

Adrian Price
Clinical commercial manager, The Co-operative Pharmacy

Dave Roberts
Co-founder, myrepeats web service

Zoe Smeaton
Reporter, C+D

Julie Wood
National director clinical commissioning,
NHS Alliance



Problem 1: We’re not solving this nationally
Alastair Buxton: “When I was working as a community pharmacist, the relationship we had with the local GP practice was superb and we were a team together. So much of it comes down to those local relationships – you’ve got to invest in those and that means spending time. One of the great problems with all the work that the pharmacy bodies and the British Medical Association have been trying to do nationally is that we can produce tools but can’t nationally make local GPs and local pharmacists talk to each other. LPCs can facilitate that but you’ve still got to have willing parties on either side.”

Solutions
Hiten Patel: “We need to go back to communication and there needs to be national directions to force the issue of working in partnership with our GP colleagues. The majority of us at a local level get on with our GP practice and our GP colleagues, but we need to take communications to the next level with national requirements for us to work together in certain areas. Otherwise it’s all left to goodwill.”

Michael Cann: “If we were having this conversation in industry, you would tear up the contracts, say ‘These are the three things we want to achieve – clinical excellence, cost effectiveness or whatever goals you come up with’, and then you’d all sign up to them and off you’d go. You need very clearly articulated common goals; those need to be signed up to and if there’s a need to make them contractual then they need to be contractual.”

Hiten Patel: “Perhaps realigning the GP quality and outcomes framework to work in partnership with us would effectively force us to work together?”

Alastair Buxton: “I think that’s difficult to achieve because of the challenge of trying to renegotiate two contracts side by side. It also needs political will on both sides of the government and both the professions.”

Problem 2: GPs don’t understand pharmacists’ expertise
Martyn Lobley: “My local pharmacist and I get on like a house on fire but I told a group of colleagues I was coming along to talk to pharmacists today and their view is that doctors write prescriptions, pharmacists take the boxes off the shelves and they can’t see what all the fuss is about. When you get to things like MURs, their eyes glaze over and they either get exasperated or they walk off.”

Solutions
Adrian Price: “I think it’s about us explaining what we’ve got to offer and I still don’t think we articulate that very well. PCTs and doctors might not understand pharmacy and to some extent we’ve got to take it upon ourselves to make them understand.”

Martyn Lobley: “Pharmacists spend so much time in their training learning about pharmacology and pharmacokinetics and none of that gets back to GPs. Most GPs have no idea about those things. Put that knowledge into practice and start ringing people up. We write a publication called Prescribing Matters for the PCT and the pharmacist does most of the work – we pay him for doing it. We also pay him a bonus if we hit our prescribing incentives.”

Dave Roberts: “My pharmacy is situated in a GP surgery so we do a lot of work for the GPs with regard to chronic disease management and minor ailments, and reviewing prescribing on a regular basis. The integration has been marvellous and I think it’s where pharmacies should be – we shouldn’t be stuck on the high street, I think we need to be in those health centres, and integrated, not just co-located.”

Problem 3: Communication links are breaking down
Hiten Patel: “We’ve gone backwards a step because PCT professional executive committees (PECs) were an excellent model for communication. Where pharmacists were on PECs it was an excellent way to meet up with GP colleagues. But PECs were mostly dissolved and that communication link broken, and now we have commissioning groups where we haven’t really been invited to the table and we have been out of the loop for quite a while.”

Solutions
Alastair Buxton: “It’s probably for pharmacy to initiate the discussions where they’re not happening because we’ve got more to gain. We need to initiate them and we need peer support where people are concerned about talking to their GP.”
Graeme Betts: “I agree sometimes pharmacists and branch managers don’t have the confidence to go and talk to GPs. We try to give them the relationship skills and communication tools to do that.”

Problem 4: The professions are fighting over the same money
Alastair Buxton: “GPs and PCTs will fall out sometimes at a local level because of the cash and where the PCTs spend that.”

Julie Wood: “You’re right that the issues are around commissioning – if you are both trying to dabble in the same pool for the same resource that’s where some of the tensions can come in.”

Solution
Julie Wood: “You need to think about making the commissioning clusters or whatever they become aware of what the added contribution and value of an enhanced community pharmacy service can be because some GPs won’t know that. Not all PCTs have got fully behind things like practice-based commissioning and because they don’t have to have a pharmacist around it has been seen by some as an optional extra.
“PCTs need to get the message that they must grab hold of the big issues and that with pharmacists also in the decision-making process then they can redesign services in a way that we haven’t yet thought of.”

Problem 5: Pharmacists are still seen as shopkeepers and not as clinicians
Martyn Lobley: “It’s funny how patients often say pharmacists have ‘given’ them something. Pharmacists don’t give things away, they’ve sold them something. Many GPs still think of pharmacists as shopkeepers and that a lot of what pharmacists sell over the counter is either useless or inappropriate. The running joke is that when doctors find out that something doesn’t work we let pharmacists sell it in half doses.”

Solutions
Graeme Betts: “The problem is the funding system – at the end of the day we’re supplementing a declining NHS income with other things.”

Adrian Price: “I’d counter that because there are a lot of evidence based medicines available over the counter now as well.”

Michael Cann: “You also can’t forget that it is government policy to move medicines from POM to P and there are very useful healthcare OTC categories.”

Martyn Lobley: “But you’ve got to stop selling placebos and pretending that they are medicines.”

Senators’ top tips for building links with your GP

“I’d urge people not to stray outside their bounds of expertise. We don’t expect pharmacists to be diagnosticians so please don’t pretend to be, and don’t expect us to be pharmacology experts because we aren’t. Let’s hear from you what you can teach us and we’ll tell you what we can teach you.”
Martyn Lobley, GP, south east London

“We’re quite innovative as a sector but we’re not given the opportunity to take that forward and best practice is not shared everywhere and that’s a problem.”
Hiten Patel, managing director, Pharma Plus

“Find your local movers and shakers in terms of commissioning, look for the win-win and work with them to develop a cast iron commissioning case, because unless you win the commissioning argument there will be no opportunities to win the provision argument.”
Julie Wood, national director clinical commissioning, NHS Alliance

“For individual pharmacists trying to develop a relationship with an individual GP practice, I’d suggest finding a little project to work on collaboratively on a clinical issue involving shared ownership. Use that to develop relationships and then build on those.”
Alastair Buxton, head of NHS services, PSNC

The Senate Ruling

1.    Communication needs to be facilitated both at a local and a national level.

2.    Pharmacists need to make the first move and ensure GPs understand their expertise and what they can offer.

3.    GPs’ and community pharmacists’ financial contracts need to be aligned.

Tips for your CPD entry on building links

Reflect     Do I work well with local GPs?

Plan          Consider how I can work more in collaboration with local GPs

Act            Implement a joint working project on a specific clinical issue

Evaluate    Has my relationship with local GPs improved?