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“I see the place where I practise as the consulting room — not the dispensary,” says Alasdair McIntyre, looking around the well-equipped clinical space where we are sitting.
It is a striking comment and one that epitomises how rapidly community pharmacy practice is changing in Scotland.
Alasdair (pictured above) is the owner of Burnside Pharmacy in Rutherglen, situated three miles south-east of Glasgow. We are talking in what used to be a bank vault. Having run his business in this small town since 2003, Alasdair bought the former Royal Bank of Scotland branch directly opposite his original pharmacy a few years ago and moved across the road.
The new premises, at least double the size of the old pharmacy, allowed him to incorporate a dispensing robot and two consulting rooms, and provide a better, more modern experience for his patients. Crucially, given the pace of change seen in community pharmacy in Scotland, it enabled him to expand the range of clinical services he could offer with prescribing playing a central role.
Pharmacists in Scotland have been able to prescribe independently for common clinical conditions since September 2020 through the NHS Pharmacy First Plus service.
However, Alasdair was an early adopter of pharmacist prescribing back in the mid-2000s, when he practised as a supplementary prescriber in local GP surgeries.
Operating under clinical management plans agreed with an independent prescriber, typically a doctor, the role consisted mainly of polypharmacy reviews for pain and depression. Much has changed since then.
With independent prescribing set to expand in a big way among community pharmacists in England in the next few years, I wanted to get a sense of what this looked like in practice at the pharmacy coalface. So, accompanied by Numark chair Harry McQuillan, the former chief executive of Community Pharmacy Scotland, I headed to Glasgow to find out.
High demand
One of several Pharmacy First Plus providers in the area, Alasdair is busy and his appointments diary full. The fact he operates a booking system at all, which some might say runs counter to community pharmacy’s open access model, is testament to the high level of demand he faces.
“Appointments were something I personally wasn’t happy with but understood they were necessary for the safety of my patients and my practice.
“At the height of the recent winter viral outbreak, we were doing as many as 30 Pharmacy First Plus consultations a day for things like chest and ear infections, on top of our regular Pharmacy First work. You need to dedicate time for this – not just for the consultation but all the administration too.
“We encourage GP practices and patients to contact us first, rather than just turn up. We’ll then determine if we can see them right away, or whether we’ll need a little more time and arrange an appointment. Most patients are fine with that – it’s what they are used to with their GP surgery.”
Alasdair’s hope is that as more pharmacies come on board with Pharmacy First Plus, he won’t need to have appointments while still allowing for a manageable workload. “If every pharmacy had a pharmacist prescriber, so many common clinical conditions could be seen away from GP practices, saving a colossal volume of appointments.
“At the moment, with a limited number of pharmacist prescribers, it puts a certain amount of pressure on us. Ultimately, however, I think the service will work really well.”
Not that it is without its challenges. The supporting IT is clunky and the administrative burden onerous. “It’s the one complaint I have – I spend so much time on admin,” says Alasdair.
“I could see so many more patients if the service infrastructure was slick and quick, but it’s slow and time consuming. We send information to the GP practice, but what each surgery does with it varies. Mostly, it has to be scanned and added to the patient record – that’s a big failing. The IT integration is poor.”
Alasdair is an experienced prescriber but nonetheless is keen to continue to develop his skills and competences, “particularly in areas outside my comfort zone”. He does this by seeking training and guidance from other healthcare professionals where he can.
He encourages pharmacists to start prescribing as soon as they can after qualification and gain as much practical experience as possible.
Training programmes like Teach and Treat, where experienced and well-established pharmacist prescribers can offer support to trainees, are also helpful in building confidence and competence.
“I see the place where I practise as the consulting room — not the dispensary”
Building confidence
“Pharmacy First Plus is an important first step because you need to give people confidence in what they’re doing,” says Alasdair. “Common clinical conditions is the way to go because you need a body of prescribers who are prescribing in the area where they work.
“We don’t have the capacity to take pharmacists away from their pharmacies to practise somewhere else. We need to deliver prescribing services where patients are and where we are.”
What about scope of practice? Alasdair emphasises the importance of prescribing within one’s competence and the need for continuous learning but says pharmacists should not wait until they are experts in every aspect of a condition before starting to prescribe. That said, he does get confronted with situations where he thinks, ‘should I prescribe for that?’.
He describes a patient who came to see him on a Saturday with an apparent flare-up of gout but hadn’t had time to go to his GP for a formal diagnosis.
“I was fairly convinced it was gout but I wasn’t confident to diagnose, nor totally sure what the treatment should be for an acute exacerbation. What worried me was – what don’t I know? So I gave the patient some anti-inflammatories to keep him going until Monday when he could see his GP.
“I subsequently chatted to his GP and arranged some training. A few months later, the patient comes in with another exacerbation, and I was able to prescribe something for him.”
Alasdair sees prescribing as an integral part of his practice and a necessary investment in patient care with huge potential to significantly reduce GP workload and improve access to the system.
“The service has been well received, with patients often referred to us by GPs when their appointments are full. The challenge now is to persuade the Government to invest in the service – that’s the rate limiting step. GPs are busier than ever. Pharmacies are well placed to take on more and prescribing is key to that. It would be a travesty if the service wasn’t extended.”
Technology driven
The use of robotics continues to transform pharmacy operations. Introducing more automation in the dispensing process doesn’t just enhance accuracy and safety, it creates the headroom necessary to provide more clinical services and secure additional NHS funding.
That’s the approach taken by Mark Feeney (below), owner of Bannerman’s Pharmacy, a group of five pharmacies situated across the central belt of Scotland in Glasgow and Kirkintilloch. Mark was fine-tuning the operation of his new Meditech dispensing robot when I caught up with him in his Possilpark branch, the ‘hub’ of what will be a busy hub-and-spoke arrangement for the business.
As at Burnside Pharmacy, nearly all his pharmacists are prescribers, providing a wide range of services including Pharmacy First, opiate replacement therapy and the weight management injections Mounjaro and Wegovy – “a real growth area in the last six months”, says Mark.
A member of Community Pharmacy Scotland’s board and a former pre-reg pharmacist at Bannerman’s, Mark completed his independent prescriber training in 2020 and, despite a hectic schedule, still manages to spend most of his working week in patient facing roles. So what does prescribing look like at his small group of pharmacies?
“Most of it is done through the Pharmacy First Plus scheme, which we currently operate in four of our five sites,” says Mark.
“We run it as a walk-in service, although we are looking at putting in place an appointment system, simply because demand is increasing so quickly as more patients are signposted from general practice. We occasionally prescribe out of hours providing unscheduled care and for our travel vaccinations service, which is picking up again after Covid.”
Growing footfall
Increasing patient demand for face-to-face interactions drove Mark to look at how he could standardise or automate the technical aspects of the job so that his pharmacists have more time to see patients.
“The pinch-point now is the door opening and people coming in for advice. Prescription items are going up gradually, but footfall and demand for our pharmacists’ time has gone up exponentially in recent years,” he says. “I try to make sure that we have the infrastructure, technology, hardware and software in place to meet that patient demand.”
Pharmacy is almost a victim of its own success, Mark believes. “I’d like to see the Scottish Government recognise the increased workload and growing numbers of consultations, and hopefully this will be reflected in future contract settlements.”
Prescribing is central to the care offer at Bannerman’s and the career development pathways of its pharmacists, all of whom are wearing medical scrubs.
“For our pharmacists to reach the highest level in the business, they have to be prescribers. That’s a key requirement of the role. I want people to recognise that we are one of the more clinical pharmacy operators. It’s an important differentiator for us and an essential part of our company ethos.
“Nothing upsets me more in pharmacy than a patient getting passed from pillar to post and no one taking ownership of their care,” he continues. “I don’t like to see patients having to go to different pharmacies for different services. Prescribing is a really important tool that gives us the ability to fix someone’s problem. And if you can do that, then hopefully you gain their loyalty. It’s simply good patient care and good business sense too.”
While the IT infrastructure underpinning prescribing is “seriously creaky and urgently needs fixing” – a common theme on my Glasgow visit – Mark can see community pharmacy taking over the management of long-term conditions in the near future.
“Pharmacy practice is changing. It is moving towards building a package of care around the patient that includes services as well as medicines supply. That is community pharmacy’s sweet spot.”
Burnside Pharmacy and Possil Pharmacy are both Numark members. What’s next for pharmacist prescribing in Scotland will be covered in part 2 of this series, online soon.
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