Pharmacists may well have been the most underutilised resource in healthcare. Highly trained, highly knowledgeable and highly accessible – with pharmacies open for longer than GP surgeries in many parts of the nation, and visited by patients more often – these healthcare professionals are typically the first port of call for those with long-term health needs in any community.
They are, in short, ideally placed to play a more active role in supporting people to prevent or better manage long term conditions. In the past, however, this has proved challenging; opportunities and funding for upskilling haven’t always been readily available.
A three-year pilot project across seven regions in England is assessing how pharmacy can be integrated into Sustainability and Transformation Partnerships (STPs) and Integrated Care Systems (ICSs), capitalising on pharmacists’ accessibility and expertise to “deliver the best patient outcomes from medicines, and value to the taxpayer”
The Integrating NHS Pharmacy and Medicines Optimisation (IPMO) programme, led by NHS England and NHS Improvement aims, in the context of diabetes, to “develop and test a core set of principles that set out how NHS pharmacy and medicines optimisation can be best integrated into STP/ICSs” and involve pharmacists much more closely in the first steps of the care pathway.
Charles Odiase, Consultant Pharmacist in Primary Care and Diabetes Dacorum GP Federation (Lead Clinical Pharmacist), DUK Clinical Champion and the iDEAL group’s adviser on pharmacy, is working alongside Herts Valley CCG colleagues, Hertfordshire LPC, and two practice-based pharmacists with a special interest in diabetes, on a pilot diabetes service in the Hertfordshire & West Essex STP region. The pilot is funded from the Treatment & Care award, which comes directly from NHSE.
“It’s very new from a community pharmacy perspective,” he says. “We’re pioneering the integration of pharmacy into diabetes care so that community pharmacists can do more, better informing people with diabetes about their condition and empowering them to manage it effectively by reinforcing the Diabetes UK 15 care essentials, checking the level of diabetes distress and satisfaction with diabetes care.”
“The pilot service has evolved over the last couple of years – the Herts Valley team had done a diabetes care delivery Self-Assessment, Skills Gap Analysis for participating community pharmacists, based on the service specification of the pilot service and against recognised competency frameworks such as the TRENDUK competency framework, adapted to the expectation of the pilot service. We wanted to know: how can we ensure pharmacists are equipped with the knowledge and skills to deliver the pilot service confidently and effectively?”
“On this pilot, evolving from previous years, we’re going a step further to upskill pharmacists to think about how people with diabetes are managing their condition by adding the diabetes distress scale and Diabetes Self-Management Questionnaire. An added scope of the intervention is to empower the person with diabetes through education – knowing how to self monitor their blood glucose effectively and what to do with the results.
“Pharmacists will be able to use the diabetes distress scale to identify how the individual is coping with the condition, while the self-management questionnaires helps work out what each individual is struggling with, so the appropriate signposting and immediately needed support can be offered, such as a referral to the local diabetes dedicated wellbeing service”
“Time in consultations with healthcare professionals is limited in general practice – the average GP slot is ten minutes long, while a full diabetes review is often fifteen to twenty minutes long on average. This scheme ensures that what the individual is offered is valuable to them and complements what other healthcare professionals have done in their limited clinic time slot; healthcare professionals are encouraged to refer to the community pharmacist to support the person with diabetes.
“Community pharmacists can support GPs and other diabetes related team members in ensuring people with diabetes get the right care at the right time, by increasing opportunist diabetes self-management and emotional wellbeing reviews, as well as check they’ve had their regular annual retinal screening, foot check and so on, where appropriate.
“At the same time, it improves the quality of the workload of GPs and diabetes specialist teams – they’re more likely to see individuals with diabetes at the right time before, for example, a foot issue becomes complicated or when diabetes has become so overwhelming that they have stopped engaging.”
“It’s intended that people with diabetes who engage in this community pharmacy diabetes pilot service will become better informed about their diabetes before they walk into the surgery for a review, therefore putting them in the driving seat of their care planning as they get to ask questions they now find most valuable.”
“This initiative does address one of the key priorities in the 2015 NHS Five Year Forward View: the need to create new models of care and break down barriers between organisations. Community pharmacists will have access to the PCN pharmacist, who oversee the GP surgeries to whom they can refer queries, and vice-versa for GPs to work more closely with community pharmacies. The practice based pharmacists with a special interest in diabetes are also offering mentorship for those community pharmacists who would benefit from additional support.
Have there been any challenges along the way? Of course – but the Herts Valley team, of which Charles is a member, has reviewed the last two years, ironing out those wrinkles in the pilot service. “There are some uptake issues,” he says. “Community pharmacists are generalist clinicians, they’re under lots of strain, and they have many obligations and priorities. So we’re engaging those community pharmacists who have the capacity to engage and exploring other localities beyond the initial pilot site.
“We spent years one and two tweaking the scheme, working out exactly where the knowledge gaps are and what training and support community pharmacists may need. Now we’re intending to embark on evidence gathering – assessing medication use behaviour, diabetes distress and self-management outcomes from pre and post baseline. We’re hoping to publish that evidence at the end of the pilot year, which will hopefully contribute to a wider understanding of how to improve population health with community pharmacy as part of the diabetes care delivery pathway.”
The previous year feedback from people with diabetes has been encouragingly positive: “People with diabetes are reporting learning more about their condition – that the scheme has given them more understanding about their medication.”
So could the integration of pharmacy into Primary Care Networks really transform the diabetes care pathway? If all 66,000 of the UK’s community pharmacists’ roles were to be interlinked with those of GPs and diabetes related teams, that seems likely. With upskilled healthcare professionals, we can empower more people with diabetes to better manage their condition – and improve health outcomes at scale.