Why Every PCN Should Consider Pharmacist-Led Chronic Disease Clinics

• 14th November 2025

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Pharmacist-led chronic disease management involves clinical pharmacists taking the lead on structured reviews, medicines optimisation, and ongoing monitoring for conditions such as hypertension, diabetes, asthma, and COPD. For PCNs, this approach helps manage growing long-term condition workloads while improving continuity of care and supporting safer prescribing across the network.

1. What Do We Mean by Pharmacist-Led Chronic Disease Management?
2. The Advantages of Pharmacist-Led Chronic Disease Clinics
3. What Pharmacist-Led Clinics Typically Cover?
4. How to Implement This Model in a PCN
5. How Core Prescribing Solutions Can Help

Key Takeaways:

• Pharmacists are trained to manage long-term conditions safely and effectively.
• Shifting the appropriate chronic disease workload to pharmacists reduces GP pressure.
• When structured well, this model improves patient outcomes, capacity, and continuity of care.

What Do We Mean by Pharmacist-Led Chronic Disease Management?

Pharmacist-led chronic disease management refers to clinical pharmacists in primary care taking responsibility for reviewing, monitoring, and supporting patients with long-term conditions.

This typically includes running clinics for hypertension, type 2 diabetes, asthma, COPD, and other conditions where medicines play a central role. In these clinics, pharmacists review treatment plans, adjust medicines within agreed protocols or under independent prescribing authority, provide lifestyle guidance, and ensure regular follow-up.

The Advantages of Pharmacist-Led Chronic Disease Clinics

• Better capacity and appointment availability: Freeing GP time by shifting appropriate review and monitoring activity to pharmacists.
• More consistent medication review quality: Pharmacists provide structured, evidence-based reviews with a clear focus on optimisation and safety.
• Improved safety through regular follow-up and monitoring: Ongoing review helps identify issues earlier and reduces the risk of medicine-related harm.
• Enhanced patient education and self-management: Pharmacists spend time explaining treatments, supporting lifestyle changes, and improving patient confidence.
• Supports proactive care rather than reactive care: Clinics are designed to maintain stability and prevent escalation, rather than responding only when problems occur.

“When pharmacists lead chronic disease clinics, you get consistency, safer prescribing, and a level of medicines-focused oversight that is difficult to achieve in a busy GP rota. Pharmacists have the time and clinical training to optimise treatment properly, follow up regularly, and coach patients on how to manage their conditions day to day. That combination of structure, continuity, and patient empowerment is what genuinely improves long-term outcomes”

Adeem Azhar: Co-founder and Chief Executive Officer of Core Prescribing Solutions

What Pharmacist-Led Clinics Typically Cover?

Pharmacist-led clinics are structured to provide consistent, proactive support for patients living with long-term conditions, focusing on safe, effective use of medicines and ongoing monitoring.

• Structured medication reviews to assess effectiveness, safety, adherence, and potential interactions.
• Titration and monitoring of long-term condition medicines, following agreed clinical pathways or independent prescribing scope.
• Diagnostics and monitoring protocols where appropriate, such as blood pressure checks, spirometry follow-up, or HbA1c review.
• Lifestyle and self-management support, helping patients understand their condition and make informed day-to-day decisions.
• Care coordination with GPs, nurses, and community services to ensure continuity and avoid duplication or gaps in care.

How to Implement This Model in a PCN

To introduce pharmacist-led chronic disease clinics effectively, the model needs clear structure, defined responsibilities, and consistent pathways that support safe day-to-day delivery.

• Agree on clinic priorities based on local needs, for example, cardiovascular risk, diabetes management, or respiratory reviews.

• Establish clear referral and escalation pathways so everyone knows when and how patients are booked into pharmacist-led clinics, and when to involve a GP.
• Define roles across the team outlining what clinical pharmacists lead, how pharmacy technicians support, and where nurses and GPs provide oversight or input.
• Ensure structured induction, supervision, and MDT integration, so pharmacists have the context, access, and support needed to work confidently within the practice.
• Monitor outcomes and refine the model, using data such as appointment capacity, BP/HbA1c control, and medicines safety indicators to guide continuous improvement.

How Core Prescribing Solutions Can Help

Core Prescribing Solutions supports PCNs and GP practices to design and embed pharmacist-led chronic disease clinics in a way that is safe, consistent, and aligned to local need. We work with teams to develop clinic structures, map workflows, set clear roles across the MDT, and establish referral and escalation pathways.

Our support also includes ARRS workforce planning, outcome measurement, and training to ensure pharmacists and pharmacy technicians are confident and integrated into day-to-day care. The aim is to strengthen capacity, improve patient outcomes, and ensure sustainable, high-quality management of long-term conditions across the network.