Meetings and Conferences

South East Pharmaceutical Industry Group

A “fly in the ointment” or “part of the team”. These were two views expressed about the prospect of pharmacist prescribing at a seminar on prescribing issues organised by the South East Pharmaceutical Industry Group with support from the Wessex and the London and Thames Valley Pharmaceutical Groups held at Guildford on 22 May. Angela Alexander, pharmacist and independent researcher, reports

Prescribing: an agenda for all professions

Opening the meeting June Crown, chairman of the Review of Prescribing Supply and Administration of Medicines, commented on the parallel of the timing when her report recommending extending prescribing was introduced with the current situation. Her investigations began in 1997 at a time of impending government change. She was pleased, however, that all these developments had received cross-party support. The review had been necessary because of changes in professional education and training, patient expectations, professional relationships and the range and complexity of medicines.

The current extension of nurse prescribing was not the route she would have recommended to take prescribing forward safely. She felt that specialist nurses in whom we had confidence to prescribe should have been the focus. Caution was needed to ensure that walk-in centres and direct access centres did not create problems; they were a potentially difficult area to manage.

The Health and Social Care Act recently put though Parliament had followed the course of its predecessor. Once again it enjoyed wide party support. It was robust and provided for change over the next 10 years. Prescribing rights to those professionals named, professions supplementary to medicine, pharmacists, optometrists and osteopaths, would be enabled “when the case is made”. It demonstrated the confidence that the Government had in the staff working in the Health Service.

Difficulties

Alison While, professor of community nursing at King’s College London, spoke of the difficulties in translating into practice the lessons learnt from the nurse prescribing pilot projects. All specialist community nurses had now been trained to become prescribers, but they were a heterogeneous group. They did not all have the same education background or experience. Her research had demonstrated that pilot projects could not necessarily be used to inform the future. The pilots had been carried out in areas of a stable workforce within integrated teams. Replication of pilot work could not be expected to inform the rollout.

There seemed to be two groups forming: prescribers and reluctant prescribers. Three months after training some had not prescribed at all; increasing anxiety and the lack of confidence had meant they could not put pen to paper. There had been a lack of research into aspects of nurse prescribing. The enablers of and inhibitors to prescribing had not been identified. One component seemed to be the practice context. It could be expected that where interdisciplinary teamwork was poor this inhibited prescribing. “Option 3” for the extension to nurse prescribing cleared the air, and most of the uncertainty was over. The Government’s intentions regarding extension depended now upon the production of statutory body regulations and the speedy publication of which POMs would be included. The reality of when it was likely to be rolled out into practice was that the education could be achieved by spring 2002, but it was likely that statutory body regulations would be awaited.

There were increasing pressures on primary health care though the NHS plan, especially with regard to access to health care professionals. Public expectations were raised. The national service frameworks, and cancer and learning disability strategies, all added to the demands against the background of a shortage of staff.

The way forward was to recognise that the nurses’ role needed to be adjusted in order to accommodate prescribing. Robust nurse prescriber education was required together with recognition of the ongoing education needs of nurse prescribers. There were difficulties in educating people half way through their professional lives and compensation was needed for the varied educational experience. Research was also needed to inform the support mechanism necessary to promote effective prescribing by nurses.

Professor While believed that nurses had had an idea, which was just a contextual idea, foisted upon them. There was confusion and extra bureaucracy as a result, which was not beneficial from a patient viewpoint. It was a difficult path to tread. She did not want to imply that nurses were not up to the challenge but there was a need to recognise those challenges.

The prescribing agenda

Giving an overview of prescribing as an agenda for all professions, Dr Derek Munday, chairman of the executive committee of Wokingham Primary Care Trust, said that safe, economical and effective prescribing was a team responsibility. All issues needed to be faced by all team members. The corporate nature of PCTs gave the best opportunity the NHS has ever had. The realities were that no Western nation could afford unlimited health care for all of its population. Wokingham PCT had limited budgets. There was no bail out; they had to balance the books. Prescribing within budget was possible without compromising patient care.

Using statistics based on research in Northern Ireland and Merton, Sutton and Wandsworth, Dr Munday said that repeat prescribing accounted for 66 per cent of all prescribing and 80 per cent of the cost. It was estimated that 50 per cent of people on long-term medication do not comply with their treatment, and that 40 per cent of repeat medication was wasted. If these figures were true for Wokingham, then a third of its prescribing budget was wasted.

The long-term objective for prescribing across the PCT was to make it so effective, efficient and economical that discussions on the drug budget were able to concentrate more on how to spend money on behalf of patients, rather than on how to save money. They had to look beyond the doctor-patient relationship and enter into the area of population medicine. The key was teamwork.

An industry view

Rob Walton, policy development manager at Pfizer, presented an industry viewpoint, which in general supported the extension of prescribing. There was an opportunity to maximise efficiency through better use of health care professionals.

The Crown II report had received massive cross-political support. It was a well developed, researched and presented report and a credit to June Crown. The industry supported the extension of prescribing because it increased access to medicines. It was also a well-thought-out use of resources at a time when health care was likely to lose a significant number of GPs.

Mr Walton thought that extending prescribing was closer to the ethos of the NHS, ie, universal health care free to all at the point of delivery based on clinical need and not ability to pay. Currently there was universal health care, only from doctors, free to all at the point of delivery, only by doctors, based on clinical need diagnosed only by doctors.

Four key considerations crucial to success were volition, skills, training and support. Many people within the nursing and pharmacy professions might not want to prescribe, and notice had to be taken of that. The objective ability to make a prescribing decision was not an easy task and could be stressful. High-quality, professionally accredited training was required, with access to high-quality, continuous professional and personal development, mentoring, and learning networks. Training was the critical success factor. For many professions, medicines management made up no part of an already extensive training programme. E-technology provided an excellent opportunity to develop comprehensive and flexible training materials.

The industry had been a partner in the NHS since its inception but only lately had there been any moves by the NHS to embrace this. There was a need for a concerted effort to draw on the expertise, experience and resources that industry can provide.

Mr Walton felt that the agenda was very much nurse-based and the system was moving at two speeds, in favour of nurses. There were already 20,000 trained district nurses, health visitors and practice nurses under current arrangements. The lower investment in pharmacy could be seen to reflect the Government’s uncertainty. This could be due to the different employment and remuneration systems and the general relationship with NHS, contrasting an employee with a service provider.

From a practical point of view the consultation setting for nurses, their integration into primary care and their clinical governance were all supportive of an extension of their roles. Evidence for the nursing role was solid with regard to outcomes. Mr Walton believed this was not yet proven for pharmacy. He thought that community pharmacy was the “fly in the ointment” and seen as a competitor in the health care economy.

There were several unanswered questions: How could existing prescribing incentives affect the relationship in primary care between a doctor, the new prescriber and the patient? How could existing prescribing incentives affect the relationship between the NHS, the new prescriber and the industry? How will a new prescriber affect the local prescribing budget, and who will be accountable for it? Will new prescribers be seen as GP replacements or will the NHS make real value from the opportunity presented? Will industry be seen as an asset or an obstacle?

New prescribers provided an excellent opportunity to increase access to medicines, improve outcomes, and enhance the service. Industry still had some concerns but wanted to be part of the process.