Graham Stretch is co-clinical director of the Brentworth Primary Care Network, which covers seven practices in Brentford and Isleworth, Hounslow, and a patient population of 59,566. He was previously chief pharmacist at the Argyle Health Group.
Q. How did you become clinical director for a Primary Care Network (PCN)?
A. I’d already been doing some work around workforce in the neighbouring borough of Ealing, where we had phase 1 and phase 2 of the NHS England pilot for employing clinical pharmacists in general practice. So, I think it was because of that, and also the fact that the company I work with had also taken on a practice in Isleworth.
We had a fairly hard-fought election campaign for the clinical director position, four people stood, and we ended up with joint clinical directors. I’ve taken on responsibility for workforce, and the other director – a GP who works at Brentford family practice – is doing the operational side.
Q. What have you done in the role so far?
A. I’ve recruited a senior pharmacist with expertise in diabetes and respiratory conditions, and she starts in three weeks’ time. She will work across the network in a senior capacity and supervise two pre-existing pharmacists from phase 2 of the NHS England practice pharmacist pilot, who are transferring over.
One of pharmacists’ great fears in relation to primary care networks is that we’re going to be spreading ourselves too thinly across too many practices and therefore not able to contribute anywhere, which might lead GPs to get frustrated at the lack of progress. I’m very grateful we’ve got four pharmacists in the network already, because hopefully it will mean we can make more progress.
We’ve initially decided that pharmacists are going to help out with our extended access service, particularly in the evenings between 6.30 and 8pm, so I’m currently busy recruiting more pharmacists to help with that. Crucially, this will include a couple of community pharmacists, who will have a laptop and a list each evening to make calls around all kinds of things, including medicines optimisation, discharges, stock availability and lifestyle counselling. They will be able to work from their own pharmacy, and then we’ll also use some pharmacists that we have in our operation.
Sharing is key as well and we’ve agreed with NHS England that we will do regional network events so that pharmacists can gain peer support, because it can be quite an isolating job. We’re going to hold events for pharmacists to attend in each of the seven regions around November this year, so that people can come, meet each other and learn from each other.
Q. What are the next steps for the PCN?
A. For pharmacists, we’re going to concentrate on structured medication reviews from the get-go. The medication reviews are one of the seven national service specifications that primary care networks have to deliver. It will be a struggle for nurses and a lot of GPs to find time to do these, so there’s a real ‘in’ here for pharmacists to take ownership of that.
We’ll also be looking at safety and quality improvement work around PINCER, a tool developed by the University of Nottingham to help identify patients who might be at risk of medication-related harms. This will help pharmacists identify their caseload, which is important because we need to identify patients who will benefit most from our input. We’re also already running respiratory clinics and hope to add diabetes in the future.
The most important thing in the PCN’s first year is also to find a social prescriber. We’re lucky in our borough that we have a fairly well-developed overarching body that has links with third sector organisations like Dementia UK, learning disability charities and drug and social isolation charities. So, we are going to commission the social prescribing aspect from that team across all networks in the borough, who will then be able to access workers from multiple voluntary organisations.
For social prescribing to work we need an understanding of the local geography and what facilities and initiatives are available, such as gyms, lunch or gardening clubs, that we can refer patients to when they need something other than medication or treatment in hospital. That could be 30-40% of the patients coming through our door, which is why NHS England has made it a priority in the first year.
Q. What are the challenges and opportunities for pharmacists in PCNs?
A. If you’ve been working full-time as a clinical pharmacist in one practice with a list size of 15,000 patients, then you can realistically see quite a big caseload and manage that really quite effectively. But if you get up to the 60,000 patient list and you’re the only pharmacist, then your challenge will be how do you prove your ability and how are you going to produce outcomes across such a large number of patients.
You’ve got to pick your battles and stratify patients according to their risk of medicines harm. If you’ve got one session a week in a practice, make sure those patients who will benefit the most come in, or do consultations over the phone like we’re doing, because you can cover a lot more ground in a five or 10-minute phone call. You just have to be smart.
The benefits are that, with 1,250 primary care networks across England, we are potentially going to have 1,200 clinical pharmacists for the next five years, and I’m hugely excited about that. There are probably around 6,000 hospital pharmacists and around 1,000 GP pharmacists across the country at the moment.
In five years’ time I can see GP pharmacists being more numerous. It’s not a ‘land grab’ but I think every practice needs a pharmacist and that’s been my driver for the last five to 10 years. We need pharmacists in the mix to influence and demonstrate the value of pharmacy in primacy care.
I also hope that by working with our community pharmacists on the extended access service that we will be able to broaden their involvement out to public health initiatives, for example around sexual health, diet, exercise and obesity. I’ve already started advocating for that locally.