Enhanced clinical roles

Participants highlighted the accessibility of pharmacists as part of the general practice team, providing a complementary skill set to existing staff that enhances the provision of services provided at practices.

I’m directly contactable face-to-face by prescribers, GPs, nurse practitioners, nurses, admin team, everything. They can just come directly into my office and ask me for information. So, I’m probably more likely to be utilised clinically. In community pharmacy, you obviously have other responsibilities as well and the pharmacist also takes on the role of the manager. (Ph1)

Participants identified that general practice is a rapidly evolving role for pharmacists, who are increasingly involved with, and leading, more advanced, patient facing clinical services. These services require an enhanced level of clinical knowledge compared with more traditional pharmacy roles, with pharmacists increasingly inputting more into the clinical management of patients in this setting.

Our roles in the surgeries are evolving and perhaps new to some, but I found it on the whole to be very very positive and that the other staff have been accepting. (Ph8)

Many of the pharmacist participants described providing a higher level of clinical service facilitated through obtaining postgraduate prescribing qualifications resulting in a greater degree of clinical responsibility and accountability.

I’m in quite an advanced clinical role now. So I do a lot of diagnostics and treating myself. I’m a prolific prescriber. (Ph7)

Participants perceived the management of chronic long-term conditions, with a specific focus on optimising therapy and the provision of detailed, clinically focused medication reviews to be a key role for pharmacists in this setting.

I would see patients for medication reviews, particularly the complex ones, the ones with polypharmacy in particular come to me. It would be about making sure they are on the right regimens, making sure they haven’t got any adverse effects and maybe stopping drugs if no longer appropriate. (Ph4)

The management of high-risk medications and the reconciliation of medication provided on discharge or from a specialist setting was seen as an important part of the pharmacist’s role. The services provided are integrated into the existing practice infrastructure and the access of pharmacists in this setting to full clinical records facilitates a higher degree of clinical input. Through working in this setting pharmacists can also clearly communicate with the rest of the practice team; this includes following up on monitoring requirements, liaising with community pharmacies and updating medical records to accurately reflect patient’s current medication.

Some of my work is quite administrative, so dealing with queries, issues from community pharmacies, discharge prescriptions or hospital letters, things like that. Making sure that patient’s medication lists are correct, particularly with medicines started on discharge or in outpatients, you know, ones with shared care agreements or high-risk drugs. (Ph3)

The provision of lifestyle and preventive advice was seen as a key role for pharmacists, complementing work done by practice nurses; this would typically include signposting patients and formal interprofessional referral where required.

There is an increasing amount of work for GPs, and I think the lifestyle issues seem to get shifted down the line as to what we are able to focus on, it’s often not what the patient presents with. I think both pharmacists and nurses are good at doing that, it is about prioritising in that short time you have. (GP1)

Some of the patients had experience of having appointments with pharmacists in general practice. Those who had reported favourable experiences were positive towards the benefits for their care; with a particular focus on reviewing medications and reducing the known side-effects of prescribed medicines.

She (pharmacist) rang up to discuss the medication because they were changing my insulin. So, she was on about ten minutes going through everything that I was on to make sure I was happy, everything was balanced, no side-effects and she decided to change a couple of things that I’d been on for a number of years. She was really helpful and it’s definitely better now. (Pt1)

Some patients had not experienced services provided by pharmacists in this role; a number of participants perceived that the benefit of pharmacists resulted from the accessible locations and opening hours of community pharmacies and were concerned that the pharmacist in general practice would become another healthcare professional with whom making appointments was challenging. This was a common experience of patients when trying to make appointments with general practice staff.

You could get a doctor’s appointment more easily when we were young. But I think people tend to just to pop in a pharmacy, I think there’s more information in the pharmacy now, there is no wait for appointments and they are open all the time. (Pt3)

If you have to wait to get an appointment with the pharmacist at the doctor’s surgery, you may as well just see the doctor or whatever else, the point of a pharmacist to me is that it’s, like, around the corner and it’s easy. (Pt6)

Limited knowledge

All healthcare professional participants reported limited knowledge of basic oral health advice and would try to signpost patients to dental services where possible, but perceived that they were able to manage common conditions, such as a mouth ulcer, and provide basic oral hygiene advice.

You will get people presenting to surgery with queries around the mouth generally. Perhaps unexplained problems. It might be anything from halitosis, to soreness, to ulcers, to even presenting with dental abscess because they’d rather come to us than go to a dentist. We try to signpost them to a dentist, but we can deal with some of the minor issues. (N1)

The primary care staff participants described the presentation of patients in general practice with dental problems, such as dental pain and likely infections. Participants described limited knowledge in the assessment and management of dental infections; GPs would typically signpost these patients to a dentist, but did report a perceived duty of care to help this patient group if the patient was unable/unwilling to attend a dental appointment.

Even if a GP thinks, ‘actually, I think it’s an abscess’ he or she’s got a duty of care to treat that infection and not to leave it, even if we don’t know a great deal about more complex dental issues. Especially when they say they don’t have a dentist. (Ph10)

Participants had limited knowledge of the links between oral and systemic health; with oral health advice not usually forming part of discussions with patients in high risk groups, such as those with diabetes and with multidisciplinary diabetes teams not including dental professionals.

I haven’t really heard of links between the two. I see lots of patients with diabetes and it is definitely not something that I would tell patients about. (Ph5)

Although not a direct focus of interventions, pharmacists described a key role in the deprescribing of medications in patients with a high anticholinergic burden. These patients would typically have symptoms of a dry mouth and this would be used by some as an incentive to stop or reduce implicated medicines.

I look to stop some medicines during medication or falls reviews, medicines that have antimuscarinic side-effects, so like those for urinary incontinence or tricyclic antidepressants that cause, like a drying effect, and patients experience dry mouth. (Ph1)

The pharmacists were aware of MRONJ, mainly due to historic Medicines and Healthcare products Regulatory Agency safety alerts. The actioning of these alerts was described as a key role of the practice pharmacist; participants reported that following safety alerts patients were identified and provided signposting advice, however, pharmacist and GP participants acknowledged that these alerts are often forgotten or lose focus and need to become longer term initiatives, not isolated alerts.

I remember a couple of years ago, there was an alert and where we set it up so that all new patients going on a bisphosphonate got told to have a dental check-up before they went on. Now, I don’t know—I haven’t seen anything around that lately and I’ve got a feeling that might have lapsed a bit. Or at least I’m not aware of it happening. (Ph4)

The patient participants identified that their knowledge in relation to oral health had almost exclusively come from their dentist or their parents as a child. None of the participants described receiving any oral health advice from other healthcare professionals.

I think it would be from my mum and dad and then the dentist. I don’t think anyone else has ever talked about oral health with me, maybe the school nurse a long time ago. (Pt5)

All participants described a need and willingness to receive further education and training on oral health; this was perceived as a deficit in both undergraduate training in post-registration continuing professional development.

I think it would be useful to have more training—directed at general practice. I think most of us know the basics, but not really much depth, especially around how oral health and just general health and wellbeing are related. (Ph3)

Geographical/situational isolation of the dental team

General practice staff reported limited collaboration with dental colleagues in primary care, with no formal referral pathways between medical and dental services and a lack of communication between the professional groups. These were all seen as significant barriers to providing high quality and safe oral healthcare to patients.

I would say there is anonymity really. If you compare it with, for example, local opticians where we have frequent interactions, albeit by paper, we don’t really get any, sort of, direct contact. Not that I can recall. (GP3)

We don’t seem to engage with dentists. In fact, the only time that I ever had a proper conversation with a dentist was when I worked in community pharmacy and that would have been over an incorrect prescription or an out of stock item. And I just think, you know, there is a lot of cross-conversations that we could have. (Ph10)

There were concerns about the lack of information shared between primary medical and dental services and the impact that this has on patient safety; with dentists not having access to patient’s Summary Care Records (SCRs) and general practice staff not receiving information about the care or interventions provided in a dental setting. This included a lack of information on medication prescribed by dentists.

We would never know if the dentists had prescribed any antibiotics or anything for a patient. Yet, if anyone else in the primary healthcare team prescribes anything for our patients, we know. We would get either a letter or a fax summary, something sent over to say this is what’s happened in this patient. (Ph7)

Both patients and the healthcare professionals described their own and their patient’s reluctance to engage fully with dental services; barriers include the cost of both preventive and remedial dental work, dental phobias and a lack of education on the benefits of good oral health.

The area I am in is very deprived and actually, I would say that the majority don’t ever visit the dentist, I think they just don’t see it as important and loads of them just don’t have the money, and fear, loads of people hate seeing a dentist unless it’s absolutely necessary. (Ph5)

The patients also reported a perceived segregation between the dental and medical professions, with historic stereotyping contributing to their formative understanding of each role. This was described as a barrier in engaging with oral healthcare outside of a dental setting, as historically this is not an environment that patients associate with dental care provision.

I think it’s just the way society has brought us up in that the there are two defining people, dentists and doctors. Anything to do with dentists, you go to the dentist. Anything about your health you go to the doctors. They have always been seen as separate. (Pt6)

Integration of oral health advice

Pharmacists working in general practice have better access to patient medical records than their community pharmacy colleagues and are therefore well placed to identify patients who may be suitable for targeted interventions. For example, the practice diabetes register or those patients prescribed medications with oral health-related adverse effects, such as bisphosphonates, could be easily identified and invited for review by the pharmacist.

In GP practices, people are coded appropriately, as smokers, or based on specific conditions, or you could look at medications that are associated with oral complications and target those people. It is easy enough to identify potential higher risk patients. (Ph1)

Participants described the role of the pharmacist in optimising medication regimens and their specific focus on providing input into patient care through chronic disease management clinics and medication reviews. All participants agreed that the provision of appropriate lifestyle advice should form a key element of these consultations.

Generally, I think pharmacists can focus on medicines and do a really good job getting those right, but with the, let’s call it, soft interventions, lifestyle advice etc., they seem to work better when they’re repeated by various people. (GP3)

Participants reported that consultations with the pharmacist are typically less time pressured than GP appointments; with most pharmacist participants not routinely involved in providing acute care. This time could facilitate the provision of more detailed consultations, representing an opportunity to incorporate oral health advice into current practices.

My clinics could easily be timetabled for 20 min instead of 10, and as I don’t really see acute patients or have the same time pressures as some of the GPs or practice nurses. I can talk longer and to go into more detail about things, there is scope to take more time and really reinforce the key messages. (Ph2)

I don’t see any reason why you can’t promote oral hygiene at a doctor’s practice, you can promote it, give people the information so they are properly informed. Then it is up to them. (Pt2)

The incorporation of basic oral health advice can be integrated into the current role of the pharmacist; however, participants reported a need for more direction from professional bodies or the commissioners of local or national services to provide more complex interventions and to improve interprofessional collaboration with dental professionals.

There is loads that we could do and as a practice we could just do it to give a better quality of care, but if it is a paid service or linked to certain targets etc then there may be more incentive to focus on it. (Ph2)