The emphasis in the Health Service was now on facilitating the development of partnerships within the health care team and between team members and patients, Mr D. PIGGOTT (chief executive, LPCT) told the study day. It was important to pursue clinical governance to ensure the highest possible quality of service. There was also a need for an effective interface between primary and secondary care outlets.
Professor CLARE MACKIE (head of pharmacy, Robert Gordon university, Aberdeen), outlining the main features of the Crown review of the prescribing, supply and administration of medicines, said that although the review had been initiated in response to extended professional roles, its real policy driver was a concern about the legality of existing group protocols governing the supply and administration of medicines by a health professional with the agreement of a doctor but not necessarily in his or her presence. A consultation document had just been released by the Government detailing how the primary legislation would be changed to facilitate the adoption of the new protocols recommended by the review. Representations about the proposals should be made before the consultation period ended on April 18. While the Crown review only referred to England, the enabling legislation would cover the United Kingdom as a whole and so it was likely that Scotland would implement similar action at a future date.
Discussing possible new models of prescribing other than group protocols, Professor Mackie went on to said that dependent prescribing was likely to be the first option considered by the Government in detail. Under this proposal the medical practitioner would be responsible for initiating treatment following an assessment and diagnosis while other health professionals would be responsible for ongoing management of the condition, including repeat prescribing. This synergistic approach would require a good care partnership to be effective.
A second model, independent prescribing, would place the health professional as primary point of contact with the patient. This already existed to some extent, where specialised prescribing was necessary. Examples included supply of postcoital contraception by pharmacists and provision of wound management by district nurses.
A memory treatment centre operating from five sites within Edinburgh and the Lothians was described by Dr A. Phanjoo (clinical director, care of the elderly, LPCT) and Miss Joan Kelly (pharmacist member of the centre's multidisciplinary team). Dr PHANJOO said that the centre was a tertiary clinic, receiving referrals from hospital specialists. Its function was to screen, assess and monitor patients who had been prescribed the anticholinergic drugs donepezil (Aricept) and rivastigmine (Exelon), both licensed for use in mild to moderate Alzheimer's disease. Patients were assessed not only on their cognitive status but also on their behaviour and ability to maintain daily living activities. In this latter respect carers' views were extremely important.
Miss KELLY said that she believed she was the only UK pharmacist working exclusively with Alzheimer's patients. Outlining how the two drugs were used in the centre, she said that, broadly speaking, donepezil required no titration and was a once daily dose (making it easier to use when a carer was not present) while rivastigmine) did require initial titration and was a twice daily dose. Her duties included assessing the implications of using anticholinergic drugs in patients, giving information on adverse drug reactions, ensuring compliance, dose adjustment and supplying the medicine.
Introducing a session on repeat prescribing, Mrs S. McNAUGHTON (primary care and community pharmacy support pharmacist, LPCT) said that a recent audit of 750,000 prescriptions had found that repeat prescriptions accounted for 75 per cent of items and 81 per cent of the cost. There was an urgent need for regular review and tight control to monitor adverse reactions and interactions and minimise the risk of wastage.
Mrs LEONOR DUNCAN (pharmacy technician), reporting on a review of repeat prescribing for outpatients at the Royal Edinburgh hospital, said that problems identified included duplication of therapy between the hospital and the patient's GP, inadequate documentation and a lack of patient counselling. Improved communication between the hospital and GPs was needed, with periodic reviews of treatment plans.
Mr G. MacBRIDE (community pharmacist, West Calder, and co-ordinator of West Lothian pharmacy locality group) described a 28-day repeat prescription system provided in his pharmacy. Among its advantages were that requests for repeat medication could be monitored closely, compliance could be monitored effectively and liaison could be established with patients, carers and GPs. The considerable extra work created was worth while because patients received a better standard of care. Annual savings for the NHS could exceed £14,000 from his pharmacy alone through more efficient use of medication.
Dr J. MILLER (general medical practitioner, Newbattle health centre) outlined the difficulties in administering patients' ongoing medication especially with mixed paper and electronic record systems. Counselling was essential, particularly where one could expect adverse drug reactions, which reduced concordance.
Mr B. FERGUSON (community pharmacist, East Lothian, and co-ordinator of the East Lothian pharmacy locality group) described a survey of patients' perceptions of their antidepressant therapy. Questionnaires sent to 525 patients had been returned by 248. Ninety-eight per cent of those taking selective serotonin reuptake inhibitors and all those taking tricyclic antidepressants had been satisfied with their medication. Patients generally wanted support. Mr Ferguson agreed with Dr Miller that counselling was vital to ensuring concordance.
Considerable progress had been made in partnership development since the 1998 study day, said Mrs PAT MURRAY (chief pharmacist, LPCT), introducing three updates on decisions taken at that meeting.
Describing the success achieved by a clozapine clinic, Dr TIM DALKIN (consultant psychiatrist, LPCT) said that an operational policy had been established and a handbook produced for the benefit of the health care team. Blood testing procedures were now carried out on a regular and well documented basis. Links had also been forged with the primary care sector.
Reporting on developments in risk management for patients prescribed high doses of antipsychotics, Mrs JOY NICHOLSON (principal pharmacist, LPCT) said that two years ago there had been concern about patients being given doses of antipsychotics well above recommended levels. Documentation had been developed to offer guidance on how to deal with a high dose situation, noting possible adverse reactions and interactions and to help in record keeping.
Mrs ANNE GILCHRIST (senior clinical pharmacist LPCT) and Mrs MORAG WRIGHT (principal clinical pharmacist, State hospital, Carstairs) described progress with the introduction of olanzapine into clinical practice within the LPCT and at the State hospital. Treatment outcomes had been monitored at baseline and at six months. The method was believed to represent an innovative method of evaluating the use of new drugs in clinical practice.