I was very pleased to be invited to write a few words on my pharmacy career, particularly about my time as one of the first primary care pharmacists. Following a discussion about primary care pharmacy, I commented that it is really heartening how far it has developed since those early days in 1992. PIP editor Johnathan then approached me for some comment on how primary care pharmacy has changed over the years and my thoughts on current and future roles.
Why did you become a pharmacist?
In school, I was really interested in sciences, particularly chemistry at A level for which I had an inspiring teacher. I was considering chemistry but decided on pharmacy when I became aware of the defined career pathways.
Where and when did you work on your first day as a pharmacist?
Following being a pre-registration pharmacy graduate in Chester Hospitals, my first day as a pharmacist was as a basic grade pharmacist in Barnsley District General in August 1980, which was in the early days of the ward/clinical pharmacy in hospitals.
What roles have you undertaken?
Following another basic grade position in Yorkshire, I returned home to North-East Wales to manage the Drug Information Centre at Glan Clwyd Hospital, Bodelwyddan, Rhyl. The hospital pharmacy clinical diplomas were just starting and I became a clinical pharmacist tutor. After 5 years, I moved to Wrexham Maelor Hospital where I undertook various clinical pharmacy roles in ITU and Medicine for the Elderly alongside being the area’s first formulary pharmacist.
In 1991, I attended a qualitative research skills course organised by WCPPE and Cardiff Social Science School. I then undertook research locally on ‘GPs views of hospital prescribing‘ and presented my findings at a national meeting of the Drug Usage Research Group and subsequently published a letter on the results (BMJ 1992; 304: 780). This led to a pilot project in developing a formulary for a GP practice. In 1992 I was seconded half-time to the Clwyd Family Health Service Authority as clinical pharmacy advisor while continuing my formulary role at Wrexham Maelor Hospital. In 1996, following a chat after a lecture in North Wales, I was invited by Phil Routledge (Prof of Clinical Pharmacology, Cardiff Medical School) to be one of the first four pharmacists to study alongside GPs for their Diploma of Therapeutics.
My primary care role evolved through various guises to become a full-time prescribing team leader in Wrexham Local Health Board (LHB).
Where do you currently work? What does the role involve?
I currently work as a practice pharmacist and independent prescriber (IP) in a Health Board-run primary care centre, Healthy Prestatyn-Rhuddan Iach in Denbighshire, North Wales. The role is in a multidisciplinary team (MDT) and is predominantly patient facing, involving all aspects of medicines management, helping patients come to an informed or shared decision about their medicines and lifestyle interventions. The majority of my time is spent on various aspects of medication review, face-to-face in clinics, on telephone or a computer review of patients’ records.
Medication review is a complex task. At it’s most simple, I follow the NOTEARS acronym template (available here), helping patients reach the intended goals of treatment, and ensuring treatment is monitored safely. This is very much a team concern involving the patient, family or carers as well as the pharmacy team (both pharmacists and pharmacy technicians) in primary care, community and hospital. In our MDT, we work very closely with the GPs, advanced nurses, physiotherapists, occupational therapists and the administration team.
I explain to patients that as a pharmacist prescriber I work within my competence and will appropriately refer to colleagues, just as a GP refers patients to a hospital specialist. Patients appreciate this explanation. Most medication reviews and queries come to the pharmacy team. We may not be able to answer everything, but as in the prescribing scenario, we can certainly signpost to an appropriate colleague if necessary.
I have described my role fully in this blog available to read here.
When did you qualify as an independent prescriber?
In 2008 having taken the IP course at Keele University, with hypertension and cardiovascular risk as my specialist therapeutic area, which I chose as I had been involved as a formulary pharmacist in updating the health board policies in these areas. I had also taught the therapeutics of these areas as a trainer with the National Prescribing Centre (NPC).
How have you developed as a prescriber since then? What clinics have you set up over the years and what do they involve?
I have continued with cardiovascular risk, cholesterol and hypertension. Due to my experience with teaching therapeutics, medication review and conducting audits, my prescribing practice has expanded to mild-moderate pain relief, NSAID review and benzodiazepine reduction. There is an increasing demand for pharmacists to undertake more complex medication review including polypharmacy. I firmly believe this is a very complex area, and even experienced prescribing pharmacists and GPs may not be familiar with drugs and diseases and will need to consult with colleagues.
What do you love about your job?
The number one reason I enjoy my work as a pharmacist IP is helping patients, and getting feedback from them that my consultation and explanations have been of value. Many patients have commented on how my explanation of cardiovascular risk was better than anyone else’s and how helping them understand their medicines has been very useful. It is so rewarding receiving comments such as ‘I didn’t know a pharmacist could do that’, ‘You explained that far better than the GP did’, ‘How do my relatives get to see you?’. Such positive patient feedback contributes to my revalidation portfolio. I also enjoy being valued as a key member of an MDT by colleagues and seeing the keenness of young colleagues.
What have been your career highlights?
Seeing how primary care pharmacy has developed. In my early primary care days in 1992, whilst in a half-time role and with a one day/week medical advisor, we were supposed to monitor and support the prescribing of 72 practices across Clwyd. Years later, as prescribing team leader in Wrexham LHB, my team became accepted within every general medical practice. Now across primary care, we have many pharmacists and technicians supporting many practices. The demand from practices is continuing to rise as medical and management colleagues understand the potential of pharmacy professionals. The role has also changed, from predominantly financial savings to predominantly patient facing, with pharmacist IPs, pharmacists accepted in general medical practices and leading seminars for GPs on evidence-based practice and the creation of consultant pharmacists. Seeing the variety and number of different roles pharmacists have in primary care, including prescribing clinics in many specialities shows how far we have come.
What aspects of your work have been the most challenging and why?
In our wonderful NHS in which I am immensely proud to have served for many years, there are many challenges. For me, one challenge was working on drug budgets, and between the general/finance managers and the GPs trying to help both understand each other more. Drug budgets have increasingly come under more pressure. Reviewing the performance of poor performing clinicians was another particular challenge, but all of these tasks are easier as part of a team.
Are there any aspects of your work that you dislike?
On occasion, it is frustrating when we as clinicians, encouraged to work at the top of our license, may due to organisation factors be diverted away from patient care to administrative tasks. This seems inefficient and contrary to the NHS Wales Prudent Healthcare Initiative – the element ‘ only do what only you can do’, appropriate skill mix and maximising efficient use of the NHS resources.
What have been the toughest lessons to learn?
Sometimes the next steps on our career path may not be our initially preferred step. Doors may close but other doors may open but as the poster given to me by my daughter, which hangs in my study alongside my certificates, marathon medals and family photographs, says:
‘Life isn’t about waiting for the storm to pass, it’s about learning to dance in the rain‘.
Who has been particularly influential in your career?
I have had so many inspirational pharmacists and medical colleagues and the names here are by no means exhaustive. Medicines information (MI) lead Brian Hebron when we were working in Rotherham District General Hospital in the early 1980s. Mike Spencer lead pharmacist at Welsh Medicines Information Centre Cardiff when I was Glan Clwyd Hospital MI lead in the mid-1980s. My colleagues Mike Pollard and Steve Keeling chief pharmacist and deputy at Wrexham Maelor Hospital, who encouraged me in my roles as formulary pharmacist and Drug & Therapeutics Committee secretary in the late 1980s and my early primary care roles from 1992 onwards.
GP Phil Alstead who was my designated medical supervisor when I did the IP course. Phil and his GP colleagues Tracey Williams and Pam Linney who were so welcoming of a new naïve prescriber in their ranks.
Colleagues at the NPC and later NICE, particularly pharmacists Jonathan Underhill and Andy Hutchinson, and doctors Neal Maskrey, Martin Duerden and Louise Bate. It was such a supportive inspirational group demonstrating how pharmacy and medicinal colleagues can work closely together to develop and implement evidence-based practice. It has been such a privilege to work with and learn from all these dedicated professionals.
What is your advice to the next generation of pharmacists?
As I’ve mentioned, I have seen primary care pharmacy develop from a tiny few to the rapidly expanding sector it is now. There is absolutely no reason why pharmacists cannot continue to develop services and patient care in many areas which may only be in their infancy now.
Pharmacists are in demand in many areas, which is great for the profession. We should be careful to manage expectations. If GPs or purchasers demand services outside our competency we should be very careful and seek to help them to understand what we can safely provide. Then gradually carefully expand that competency.
The RPS Foundation to Faculty lifelong portfolio is a very useful framework for professional development. I have written a blog on my Faculty and prescribing journey available to read here.
It is always useful to build networks of trusted colleagues and mentors to ask advice. Ensure we have the data or the research to back up our services. Collect and learn from all feedback, compliments or areas to learn. Gain a reputation as a trusted colleague within pharmacy, the MDT and most importantly for providing sound advice to our patients.
Do you think all pharmacists should be independent prescribers?
That’s a ‘Yes, it depends’.
We have to be confident as a profession, that as we are the ‘medicines experts’ then we should step up to the mark with prescribing. Our medical colleagues prescribe from day one in a supervised hospital environment as Foundation 1 doctors. Our nursing colleagues are pushing for early independent prescribing. The profession should set up appropriate governance safeguards to allow all pharmacists to prescribe, within competence. Once set up then within appropriate safety structures all pharmacists could prescribe; patient safety is paramount.
Are you optimistic about the future of pharmacy?
It is exciting to see the developments in pharmacy. When I qualified there were no pharmacists in GP practices or prescribers; we have come on an amazing journey. There are many new roles for pharmacists in primary and secondary care, community and cross-sector.
I am confident that the profession has an exciting future, we need to continue to step up into new roles of patient care. For example, why not have many consultant pharmacist roles in primary care, a consultant pharmacist in every cluster or even every practice?
What’s next for you?
I’ve recently completed my 51st marathon so obviously to complete 100 marathons would be a great next goal! In 2018, I competed in the Comrades ultra-marathon, a 90k road race from Pietermaritzburg to Durban in South Africa that has to be completed in 12 hours; I didn’t quite make it, running 87.5k in that time, though through sponsorship friends helped me raise nearly £2,000 for two North Wales hospices. I have unfinished business with that race and plan to go back to complete the whole 90k!
Aside from running, continuing to support my beloved Wrexham FC and see them gain promotion. It’s about time!
Maybe you mean what’s next for me in pharmacy Johnathan?
Pharmacy is fulfilling. I’ve recently adjusted my life-work balance to a 3-day working week. I am continuing to practice as a pharmacist prescriber within the MDT that is Healthy Prestatyn-Rhuddlan Iach. I have an increasing role mentoring and guiding younger pharmacists and our integrated preregistration graduates, as a sounding board for where pharmacy can take them. Alongside this, I believe I make a valuable contribution as a grassroots pharmacist to the RPS Welsh Pharmacy Board and as Wales rep on the Faculty and Education Board. I do believe we should make the most of our time as ‘We come this way but once‘ and we should ‘seize the day‘.
It has been an amazing journey in primary care pharmacy over the last 27 years. I am excited to see how colleagues can develop this exciting field of patient care to levels we may not even have yet dreamt of.