The team started getting involved in the management of repeat medication for patients with chronic conditions in 2019. Sparked by their belief in prudent healthcare, structured training was planned for the team members to upskill them so that they can provide support in the implementation of monitoring and safe prescribing in the practice.

During the development phase of primary care monitoring for chronic disease management, the realisation struck that not all patients with diabetes were having their urine ACR done. After investigation it was found that the protocol followed by HCAs did not include ACR, hence it was being missed; they were continuing to dip the urine, which was also not happening for all the patients. The protocol was therefore updated and this work was prioritised by employing EMIS searches for all the patients who have diabetes in their problem list yet had not had an ACR in the past 12 months. Bloods and ACR requirements were then identified and requested, and the pharmacy technicians flagged all patients with ACR higher than three in which their history, medications and renal functions were reviewed.

As a result of this activity, the team removed thiazide diuretic where it was an inappropriate choice and changed antihypertensive / introduced ACEi or Alpha 2 antagonists based on clinical appropriateness.