Pharmacist in practice: 'We need more joined-up thinking in pharmacy'

As part of our Pharmacist in Practice series, we spoke to Iain Speirits, an advanced pharmacist in primary care based in Townhead Health Centre Glasgow.

How long have you been working in general practice and what were you doing before? What attracted you to working in general practice?

I’ve been qualified just over 20 years. I’ve worked in Glasgow basically since I qualified, I studied at the University of Strathclyde and I live in Glasgow, where I’m from. I split my job half and half between cardiology clinics for left ventricular systolic dysfunction, which is a precursor condition for heart failure after a heart attack. The second half of my week I spend in general practice, in a pretty deprived area of north-east Glasgow, and I’ve done about 15 years there.

I started with them in a full-time general practice role. I qualified in 2002, did about 18 months of community pharmacy and thought it really wasn’t quite for me. A couple of general practice jobs came up that were advertised as part of a new wave of posts in NHS Greater Glasgow & Clyde, I went for one of those and was assigned two GP practices. I worked in a few different GP practices for a while, rotating round, and then I graduated to only working in north-east Glasgow and then pretty much only in Townhead.

What does your job look like day-to-day?

There are two main aspects. One is trying to deal with the quantities of acute prescribing that we have, for example requests for painkillers, hypnotics or antidepressants. These medicines we try and review quite regularly. We have near-patient testing, bloods for kidney and liver function for patients on rheumatoid arthritis drugs, for example Sulfasalazine.

The other aspect of the job is the patient-facing clinic, so we get people who enter the practice who have high blood pressure, diabetes, chronic kidney disease or heart disease. We bring them in, review and optimise their medicines and we’re trying to drive key outcomes like improvements in blood pressure, cholesterol and HbA1c, as well as quality of life, cardiac function, breathlessness.

Then you can look at at whether the practice is prescribing well or could do better and what you can look at to target and improve.

What is the biggest patient need in your area and how does that influence your work?

About a mile from us we’ve still got male life expectancy that’s in the 50s unfortunately and areas of deprivation. A lot of people develop chronic disease at a young age – there’s lots of premature heart disease, lots of young age COPD, so most of the demand is driven by the complexities of the local population.

How do you work in a team with your practice colleagues?

It’s a large health centre with two wings – I’m a Band 8a and I have a Band 7 pharmacist who works with me as well who’s just completing her prescribing qualification. We’ve got a pharmacy technician and a pharmacy support worker as well. I manage that small team and help them develop their roles and increase their competencies.

And in terms of the other healthcare professionals, we have discussions with the practice healthcare assistants, the GPs, about what’s important to them, how we can improve the quality and safety of the prescribing and what their objectives and priorities are.

How do you work with community pharmacists?

I find myself speaking to community pharmacists on most days of the week, and it’s usually for one of two things. It’s either to get advice, because we seem to have been facing a lot of shortages, so I want to get a bit of insight and understanding into what’s gone on.

The second thing is trying to explain what we’re trying to work on, for example benzodiazepine reduction, ongoing diazepam prescriptions where you’re gradually trying to bring people’s dose down and explain to the pharmacist why we’re giving them specific quantities for a specific timeframe.

Are you currently undertaking any training (e.g. CPPE or IP)? How is it going?

I’m doing the RPS advanced practice curriculum and working towards all the competencies for that. And I’ve done some additional clinical training through NHS Education for Scotland, both in general clinical skills assessment and cardiology specifically, in terms of interpretation of echo, ECG, screening for atrial fibrillation, that kind of thing.

It’s fairly busy. It’s easier said than done but I try to keep cardiology to a Monday and Tuesday and general practice to a Wednesday, Thursday, Friday, but of course there’s some overlap if you’re waiting on blood results, chasing things, or writing clinic letters. There’s always going to be a bit of to-ing and fro-ing and it can be quite tricky to balance it all, truth be told.

Do you have any areas of special interest or any particular projects that you’re working on?

I’m focused on improving care and reducing variation of cardiovascular disease, for which you need to think about the population that you’re working in. Trying to reduce inequality usually involves being proactive with people who have a lot of problems going on in their lives, a lot of difficulties, perhaps poor health and education levels, and sometimes not great understanding levels at all.

So, you have to work a bit harder with these people, you have to spend more time with them, you often have to involve families, friends, carers, write things down for them in a bit more detail. Just be generally a bit more patient and understanding and appreciating that what you’re trying to get across to them is possibly way, way down their priority list and there are maybe more pressing things for them in terms of family pressures, social housing, unemployment, quality of life, smoking, unwell relatives. You need to take these into account and that’s quite challenging. Reducing health inequalities is really difficult, but my take on it is that I choose to work in north-east Glasgow, which is notorious across Europe for having such premature cardiovascular mortality.

What do you think will be the biggest opportunities challenges in the sector as a whole, over the next five years? What changes would you like to see?

The biggest frustration that we have on a daily basis is that it feels like the left arm doesn’t talk to the right arm. Some things that are either done in primary care or secondary care where there could be much more joined-up thinking in the system. We need more joined-up thinking both in pharmacy and in different sectors of care. It causes so much duplication and wastes so much time.

We need to be careful about how we talk about pharmacists ‘taking workload off GPs’. What does that actually mean? Because if the patient needs a diagnosis and we need to understand the clinical history and run tests and then get them back and discuss the blood results and come to a diagnosis and/or referral, I would argue that’s something pharmacists are not well-placed to do in the vast majority of cases. You cannot do that without access to a full and detailed clinical history. If we mean ‘taking workload off GPs’ as minor self-limiting respiratory infections, UTIs, acute to non-chronic back and knee pain, that’s fine, but I think we need to differentiate between the serious and minor, self-limiting things. I don’t quite understand that term ‘taking workload off GPs’, because quite often GPs will come back to you and say, ‘it hasn’t really made that much difference, all I feel is more pressure’. Is that because the demand has gone up or are we making any impact on that as pharmacist, taking workload away from GPs? And I think the truth is somewhere in the middle.

Pharmacy as a field is incredibly stretched. My community colleagues are working nine-plus hours on their feet without a proper break at all, it’s constant demand and chasing. There has to come a point where you ask, is it safe, sensible and practical to add more to people who are already pushed? Without addressing the shortfall in the support staff and working conditions, it’s going to be really difficult.

If you can address that and you can give pharmacists well-organised, good quality, high service level pharmacies, and I have seen them, where they have enough support staff, a second pharmacist, robotics, a good workflow etc. If they have these things then the opportunities are infinite, why can’t you take bloods, have a chronic disease clinic, a patient caseload? There’s no reason these things can’t be done and people can’t be upskilled to do them, but you have to look at resource and capacity and I think right now that’s the bottom line.

We’ve got a very long road ahead to get to where I want things to be. We’re moving very slowly away from a supply model to how well you can show your value and worth, how that impacts the NHS and reduces hospital admissions and outpatient clinic appointments. These are the things politicians are interested in – we’ve got to prove worth.