The Big Debate

The Big Debate

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The Big Debate #11: Should pharmacist recruitment into the ARRS be halted?

Started 2 months ago

Tonight’s discussion will focus on the question: should pharmacist recruitment into the additional roles reimbursement system (ARRS) be halted?

The ARRS, introduced in England in 2019, reimburses primary care networks (PCNs) for the salaries of several healthcare professionals – including pharmacists – as a way to help build multidisciplinary teams.

The scheme has proven controversial over the past year or so. While ARRS advocates have defended it as a means by which pharmacists can gain experience working in a multidisciplinary setting, its detractors have warned of an exodus of community pharmacists as many flock to work in primary care.

Some representative groups have even called for an end to the ARRS in light of “urgent…workforce issues” in community pharmacy, while others have suggested the need for pharmacy to have its own equivalent of the ARRS.

But with community pharmacy’s future seemingly defined by the introduction of more clinical services, it seems clear that pharmacists’ role as the experts in medicine will become more important than ever - with PCNs eager to harness these skills.

So, where along the spectrum do your own views lie? Join the Big Debate to tell us what you think.

We’ve got two speakers lined up to share their views tonight, but you can also let us know your thoughts by commenting and asking questions. The “live” part of the debate will close at 8pm, but feel free to continue to exchange views for as long as you like.

Join your pharmacy peers tonight to discuss:

- The impact ARRS recruitment has had on community pharmacy

- How it is affecting primary care

- The benefits of working in general practice pharmacy

- What can be done to make jobs in community pharmacy more attractive

C+D has introduced a streamlined functionality that allows users to mention each other in a comment. Simply use ‘@’ and type in the person’s name.

This debate will start at 7pm.

Good evening and welcome to tonight’s Big Debate. Tonight, we’ll be discussing whether pharmacist recruitment into the ARRS should be halted.

In just a moment, I’ll be introducing our two speakers. Both have extensive experience in both community pharmacy and general practice, alongside a host of other impressive experience. You can share your own views by commenting in the thread below. Remember: you can mention other users in a comment. Simply use the @ button and type in the person’s name.

First up is Mohammad M Rahman. Mo is the principal pharmacist and head of medicines at Lewes Primary Care Network and Foundry Healthcare. He is also a specialist pharmacist in preventative cardiology, an antibiotic stewardship and non-medical prescribing lead, and clinical lead for CVD QOF domains in his PCN. Welcome Mo!

@beth, thank you for having me.

Thanks for joining us! What are your views on this topic?

Pharmacists in Primary care, General practices, and PCNs demonstrated the exemplary working model of a multi-disciplinary approach where Clinical Pharmacists are embedded in the practice, and with appropriate training and expanded competence, Pharmacists are contributing the improved patient care in Primary Care. 

Pharmacists in Primary Care are actively involved in Chronic Disease Management and contribute to devising care plans for chronic diseases like Hypertension, Diabetes, Asthma, COPD, Heart failure, and dyslipidemia, and help improve patient outcomes in General practices. This leads to an overall reduction in hospital admissions and bed hours saved in secondary care. This is just an example and overview, however, some pharmacists are even working in a specialist capacity, leading Quality Improvement Projects, Leading the QOF domains as Clinical Lead, and managing minor ailments, through the Structured Medication Optimization approach, Pharmacists are ensuring the improvement of prescribing from General practices as well.  

 Pharmacists at General practice/PCN don’t only have the wonderful ability to connect with patients and become part of a team, but it is the vision of a Pharmacist for what a Primary Care Network can achieve if it works in a truly multi-disciplinary way for the benefit of its population that makes a Pharmacist in Primary care as unique and distinctive. Pharmacists from General Practices collaborate with Community Pharmacies to ensure better patient care of the mutual patients by continuing the stretch of offering clinical pharmacy services. 

My views, as always, I believe Pharmacists in General practices have made a significant difference in patient care, improved operational efficiency, and patient access. Stopping Pharmacists' recruitment from other sectors under the ARRS roles will not resolve the workforce crisis for community or secondary care. It is the respective sector's responsibility to make the job lucrative, ensure that Job satisfaction is there, and devise a plan for employee retention. Pharmacists should be allowed to make informed career choices to decide which sector they want to work in.

Thanks Mo - some really interesting points here. Sounds like you've had a really good experience in general practice pharmacy. W

What do you think community pharmacy could do to become a more attractive career option?

Next, we’ll be hearing from Shilpa Patel. Shilpa is the lead prescribing pharmacist and a GP partner at WellBN (GP) in East Sussex, as well as being a DPP and a pharmacist mentor. She also blogs regularly for C+D and has created, a valuable resource offering time-saving prescribing guidelines for primary care. Thanks for joining us this evening, Shilpa!

Hi Beth and hi Mo, thanks for inviting me to attend this evening @Beth Kennedy 

We're delighted to have you! What are your views on this topic?

Definitely against - I’m here today to explain why ARRS funding should not be halted!

I have 17 years experience working as a community pharmacist and I joined general practice under the NHS England pilot scheme in 2016.

In 2018 a GP retired at our practice and the partners at the time announced that the work I was doing saved them 1.5 times the amount of work a GP can do and asked me to find another pharmacist to join the practice. 7 years later, this month we just recruited our 11th GP pharmacist. 

I have 3 points to share with you 

1. The problem is not general practice, the problem is community pharmacy and how the current structure means for many years pharmacists have felt undervalued, disrespected and their clinical skills have been underutilised and so many of us feel like and felt like glorified shopkeepers. Why is it that all my pharmacists, who all come from community pharmacy, are willing to take a pay cut to work with me? Job satisfaction. When pharmacists join a GP role they feel valued, respected and clincally challenged.

2. Patient care should be our highest concern. I was terrified and shocked when I joined my GP practice with the reckless prescribing and GP pharmacists all around the country have increased prescribing safety by improving processes, providing pharmacological expertise and ensuring medications are accessible, optimised, monitored. If we halt ARRS funding this will have a direct negative impact on patient safety. The problem is not the GP pharmacists, community pharmacists should receive funding to enhance patient care in this way too. 

3. GP shortage – GPs do not want to be Gps anymore! And pharmacists do! I have seen first hand how difficuilt it is to recruit GPs.  My pharmacists are month by month taking roles off the GP and if you look at the overall cost – we are doing this for less money and thus saving the NHS money.

So I say the ARRS funding for pharmacists in general practice should not be halted but a review should be done to find out what is going wrong in community pharmacy, improve the working conditions, more integration between the GP and community pharmacists and really utilise pharmacists as the saviour of our NHS. 

A quick note - if anyone would like to take a look at Shilpa's LinkedIn profile, you can check it out here 

@Mohammad Mahfuzur Rahman I think this is the main issue the fact that the skills of pharmacist are uniquely adapt to helping GPs. so this scheme takes those very important skills away from community pharmacy where they are needed aswell.

I'm definitely seeing some agreement between both Mo and Shilpa. Both feel that community pharmacy can be doing more to attract and retain talent. Do we have any other participants who'd like to share their views on this?

@Shilpa Patel While pharmacists are becoming GPS who are the pharmacists going to be? dispensers?

Nice to see a double representation from Sussex Mo, I'm in Brighton, not far from Lewes! Nana, I don't understand your question? 

@NANA K OFORI-ATTA , the skills are only valued when we use those skills. The pharmacists in General practice further go for extensive 18-month training, prescribing, and mentorship to be sharpened to make sure they are comfortable/ready for the clinics, and patient care. Only recently, we are trying to introduce clinical services into the community, not long ago, pharmacists were considered and overqualified dispensers in the community...

You mentioned Gps don't want to be GPS anymore and pharmacists do. So while Pharmacists are taking on the role of the GPs doesn't that leave a gap of pharmacies with no pharmacists?

I know that pharmacists in general practice are being challenged and we are loving this. It seems in community pharmacy pharmacists are not being challenged clinically, we are being used for the wrong reasons and not for what we are good at, this may be why many feel unfulfilled.  

@Mohammad Mahfuzur Rahman and @Shilpa Patel

How do you feel when you see the big community pharmacy organisations asking for it to be scrapped? What should they be demanding instead?

@shilpa, nice to see your points, can't agree more...

Community pharmacists should be running clinics in the pharmacy and pharmacy technicians can do the dispensing and checking of medications

@Mohammad Mahfuzur Rahman I think the use of overqualified dispensers has always been unfair because in my experience, pharmacists have always been giving patients clinical advice and using their clinical knowledge to advice and prevent harm within the community.

Would you suggest we get rid of the community pharmacist role completely then?

@Shilpa Patel " community pharmacy pharmacists are not being challenged clinically, we are being used for the wrong reasons and not for what we are good at, this may be why many feel unfulfilled."

We've seen very strong signals from CPE that they see the future of community as being much more clinically focused. The recent pharmacy vision paper by the King's Fund and Nuffield Trust certainly sees pharmacists as the first port of call for primary care in years to come: 

What do you make of these proposals - will they empower community enough?

Do you possibly see yourself or others working in GP practices returning to community once Pharmacy First kicks in?

@Shilpa Patel I agree with pharmacist running more clinics in the pharmacy but doesnt funding like ARRS make it harder for contractors to retain pharmacists when their funding keeps getting cut.

@James, the ARRS scheme is not based only on Pharmacists. It includes Paramedics, Social Prescribers, Care Coordinators, Mental Health Coordinators, and Advanced Clinical Practitioners.....list will continue. So Scrapping the ARRS scheme means a number of professions would be affected. It is not for Pharmacists only...

James, I truy believe they should be asking for better remuneration of NHS services so pharmacists in the community can provide services which also help with general practice and hospital workload. Community pharmacists are an untapped resource - everyone is jus beginning to realise this. I think they should be moved away from dispesning and non clinical work and being utilised more effectively, clincially and efficiently. These larger organisations you refer to should be clooking at why pharmacists are leaving them and changing the roles to keep them happier. I ask again - why would pharmacists work for my GP practice when I pay less than if they worked in community pharmacy? They need to feel clinically challenged. 

Mo is right, if they scrap the ARRS funding now, many GP practices will go bust - I am certain my organisation will ot be able to function without the ARRS funding. 


@Nana Ofori-Atta  are you a community pharmacist? 

They could remove pharmacists from the list :)

@Nana Ofori-Atta , community pharmacies are the heart of the community. so as the pharmacists. There is no discussion of getting rid of Pharmacists. Ideally, community pharmacy contractors need to make sure pharmacists' role is valued, and respected, and quality of work life is improved in the community.

We're just over halfway through tonight's Big Debate. Are there any other participants watching the debate who'd like to share their own views as well?

@Shilpa Patel currently do the odd locums but to this question;  I ask again - why would pharmacists work for my GP practice when I pay less than if they worked in community pharmacy? They need to feel clinically challenged. 

I think they might get paid less but with the working hours and flexibility in the working day. since covid these are much more important to people than money

Exactly, James. I very much welcome Pharmacy First, I think it is very brave and innovative. I am very excited to see how this turns out - this is exactly the thing that needs to happen. Currently the GP shortage is being resolved by general practice pharmacists (and as Mo rightly reminded us, other clinicans) and community pharmacists will be developed via Pharmacy Firts services. This way there will be a balance between noth sectors. Again, pharmacists are the future! All the more reason for not halting the ARRS funding. 

@Mohammad Mahfuzur Rahman Last year a DH-commissioned report also by the King's Fund found that many GP-pharmacists "felt that GPs underappreciated their abilities or wanted them to focus on ‘tick-box’ tasks and medication reviews".  

This certainly doesn't seem to be your or @Shilpa Patel 's experience, so I was wondering what you would recommend to pharmacists that would like to be more involved and appreciate in their clinical efforts. How have you got the most out of your experience?

The contractors can't compete because unlike the GPs getting funding to employ and train pharmacists. These contractors have to do both from their business while their funding keeps getting cut and inflation and cost of living keeps affecting their profits. so community pharmacy is being hit from both sides

@NANA K OFORI-ATTA Are you saying that community pharmacies are at risk of being phased out since they can't compete? Is this putting the future of community pharmacy as clinical centres at risk?

Nana, I completely agree that it is difficuilt for pharmacy contractors, perhaps they need to work differently? Rather than revoking ARRS funding - which clearly has been a great thing - concentrate on making Pharmacy First successful, concentrate on ensuring pharmacists' skills are better used. 

The thing is that I was a community pharmacist for 17 years and I speak with community pharmacists day in and day out - and there are very few who have had job satisfaction in the last 15 years. The job is just too demanding. Our medic friends - the dentists, optitians and doctors have always had better job satisfaction, as soon as they come out of uni they are on better salaries than us and they do not feel like they are glorified shopkeepers. I believe pharmacists want to work in general practice because of the terrible working conditions we have put up with for many years and we have simply had enough! Many have found a way out and are feeling fulfiled. Patient safety has been improved tremendously and the GP shortage situation is being addressed.   

Exactly this is seen from all the recent closures within community pharmacy.

@James, General practices, PCNs have got their own challenges. Some of the PCNs, General practices, are miles ahead of others. So as Pharmacists in General practices. I am aware of that report where Pharmacists opined that, they are undervalued and less appreciated. And probably that is one of the reasons, I have noticed Pharmacists turnover in the general practices. However, I noticed the Pharmacists change jobs between General practices, and PCNs, but hardly want to go back to Community, simply because of the Quality of life....I guess.

Yes I agree but @Shilpa Patel The addition of pharmacist first is not going to reduce the demands on community pharmacist, its only going to add to it. ANd leaving this adaptation of role to contractors has never worked. its up to pharmacist to solve this problem.

What if the ARRS funding is for pharmacist who work 3days in the GP and 2days in a community pharmacy. this will help both sectors develop equally and the funding could benefit both sectors

@Mohammad Mahfuzur Rahman @Shilpa Patel I'm thinking now if GP-pharmacists like yourselves are going to be in big demand in the coming years as community pharmacies move more into clinical services - what could community do to prepare?

For instance, would additional training, better facilities, or even receptionists be needed?
What could be done to boost IP numbers in community, as this seems to be the main factor affecting workload?

@Nana Ofori-Atta , That is a great idea. I know some Pharmacists adopted that work-life as well. 

In my opinion, community pharmacy needed a shakup! We have been putting up with these conditions for so long and we cannot continue. The employed community pharmacists have a way out now - I suppose the discussion needs to be around how the contractors can survive? Thik outside the box? 

Could an idea to keep GP practices and community pharmacies happy be something like a rotational scheme operating throughout the year?

Except Shilpa when the contractors go its not just the pharmacists that go. there are dispenser, ACTs , counter assistants these places support lives and just letting them be squeezed out because of an easier shift doesn't seem fair

That links up to your question James - i think NHS and private services are the future.  I have discussed this with pharmacy owners as they need to increase income somehow. But many are too busy doing their day-today job to consider new services. There are a few new enterpreneurs out there settig up private services and online prescribing. This will allow pharmacists to be challenges clincially, feel fulfilled, provide the worklife balance we crave and utilise pharmaists best.

Just over minutes left until the 'live' part of tonight's debate ends. However, feel free to come back any time and add your own thoughts. We've heard some really interesting points tonight - including a solution that both Nana and Mo seem to have agreed on ;) 

@James, IP numbers will inadvertently increase. We are hosting Uni students with split training, in GPs and community. The batch 2025 pharmacist will come out as IPs, so it is the Community sector, that needs to be ready to make sure these new IPs skills are appropriately used.. 

*five minutes

Sorry Nana, that is not what I am saying - I feel community pharmacists are being underutilised - their skills are not being used to ther best. If they are given the opportunity to prescribe within the community setting and contractors are remunerated for this, then techs can be challenged towards takig on more of the pharmacist role and ACT, dispensers and counter staff will be needed all the more. 

A split ARRS funding as suggested by Nana seems to be a great solution and fair too!

To all, looking at the discussion so far, my take is, that it is not the ARRS role, but rather the working conditions, respect, value, work-life balance, quality of life, training, job satisfaction etc. are the determining factors of losing pharmacists from the Community... 

And thank you all...

Lovely to meet you all and to have an open and honest debate. Do connect with me on LinkedIn and have a lovely evening all.

We're now closing off the 'live' part of tonight's Big Debate - however, all of our participants are welcome to share their views whenever they like by returning to this conversation. A very big thank you to everyone who has attended tonight, including our wonderful speakers. It looks like we may even have thrashed out a solution to this debate's question - could split ARRS funding be the way forward? Thank you and goodnight!

@Mohammad Mahfuzur Rahman That certainly seems the case - and it seems to be the challenge not just for community pharmacy but for the government too if they are going to succeed in bringing about pharmacy's clinical future. Thank you for your insight!