The Pharmaceutical
Journal Vol 267 No 7177 pp824-825
8 December 2001
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The Pharmaceutical
Journal Vol 267 No 7177 pp824-825 |
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United Kingdom Clinical Pharmacy Association:
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This year’s autumn symposium of the United Kingdom Climical Pharmacy Association was held in Blackpool from 23 to 25 November |
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Dr June Crown: training and CPD implications |
Pharmacists must think about whether they want to be independent rather than supplementary prescribers [of prescription-only medicines], said Dr June Crown, chairwoman of the Royal Pharmaceutical Society’s prescribing, supply and administration of medicines task group.
She warned that concerns such as ensuring patient safety needed to be addressed before pharmacists could take on such roles. "Prescribing relies on making accurate clinical assessments. This will be difficult for pharmacists, whose training is not in the main clinical." There were, therefore, implications for training and continuing professional development. A broader curriculum for pharmacists would be required, as would extra clinical training for pharmacists who were already qualified.
The role of pharmacists as prescribers would constitute a major change in practice and required strategic review, said Dr Crown. There were issues over how fraudulent prescribing could be spotted and how misconduct would be dealt with. She added that pharmacists were in the best position to pick up prescribing problems that were generated from other professions but questioned whether pharmacists would be able to ensure that prescribing by their own profession was of a high standard.
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Prescribing roles Independent prescribing involves assessing a new patient’s clinical condition and deciding on appropriate treatment, which might involve prescribing a medicine. Dependent or supplementary prescribing involves the continuing management of a patient already assessed by an independent prescriber. |
Dr Crown said she was confident that pharmacist prescribing was the way forward but warned that the profession must address the questions that would be asked of it. "It will be much better that the profession comes up with answers rather than leaving it to civil servants," she said. Addressing the issues now would also mean that the profession could hone down its prescribing role to areas that would make the best contribution to patient care.
Another concern was access to clinical information. In community pharmacies, as with other direct-access services, prescribers might not have access to the information they require.
Dr Crown pointed out that the Government was taking the supplementary prescribing programme forward. "Pharmacist prescribing has a great deal to offer. But the profession must get on with it because the political process is moving fast."
During her lecture, Dr Crown paid tribute to Helen Remington, chief pharmacist, Addenbrooke’s NHS Trust, Cambridge and Professor Clare Mackie, Robert Gordon University, Aberdeen, for their contributions to the development of a prescribing role for pharmacists.
If community pharmacists wish to extend their role into medicines management they must think about locating their pharmacies in doctors’ surgeries or health centres, said Dr Duncan Petty, division of academic pharmacy practice, University of Leeds.
Dr Petty, winner of the 2000 AstraZeneca travel fellowship, had come to this conclusion after travelling to North America to see examples of medication review services. Such reviews worked best when the pharmacist was part of the health care team, he said. "Only when the dispensary was based in the area of clinical care and the pharmacist employed by the institution, were they able to become heavily involved in medication review and treatment decisions."
Dr Petty pointed out that in the United Kingdom, clinical review of repeat prescriptions by general practitioners was poor and that pharmacists within the National Health Service should have a greater role in managing patients’ pharmaceutical care needs.
"American pharmacists are running the types of services envisaged by the NHS plan." However, Dr Petty believed UK pharmacists would not be able to fulfil a medication review role unless dispensing was delegated.
In North America one model for medication review was the "refill centre" which supplied a patient with their repeat medicines for up to a year. Patients would ring the pharmacy to order their prescription, at which point the pharmacist could review their medicines and alter the prescription if necessary. The pharmacist could also check any monitoring requirements of the prescription.
Another model involved a patient being referred for review by their primary care doctor or by directly booking an appointment to see the pharmacist. The review would last for 20 to 30 minutes with the pharmacist able to alter doses of drugs or start other medicines according to an agreed protocol. Any monitoring that was required could be conducted at the review.
Dr Petty concluded that the blurring of professional roles was recognised as a potential problem because pharmacists were more expensive to employ than nurses. However, pharmacy managers justified pharmacists’ input because of their therapeutic skills.
The winner of the 2002 AstraZeneca award is Alice Oborne, King’s College, London.
Information gaps involving the safety of medicines exist, Dr Joseph Veltri, chairman, Pegus Research Inc, Utah, told UKCPA participants.
Currently, there are no satisfactory methods for assessing the safety of medicines when they are used in over-the-counter settings. Dr Veltri pointed out that the Medicines Act only identified practitioners of medicine and dentistry as investigators in clinical trials and did not allow the use of pharmacists. However, the European Clinical trial directive issued this year had opened the way for pharmacists to expand their role in clinical research in the UK.
Dr Veltri said that pharmacists must adopt pharmaceutical care and patient-centred services in the community setting. "The profession should also take steps to preserve the pharmacy medicine category of medicines and strive for a meaningful P class of medicines.
"If a medicine does not require intervention by a pharmacist then its move to GSL status should be supported," he said.
Dr Veltri went on to describe a trial designed to assess over-the-counter use of a prescription only medicine [see PJ, 1 December, p768].
Pharmacists should use every opportunity to counsel new and established methotrexate patients about their treatment, KATIE RIPPENGILL, Aston University, told audience members.
Methotrexate (MTX) is used in the treatment of rheumatoid arthritis and has an unusual once weekly dosing regimen, which has been associated with errors.
Miss Rippengill described a study in which patients taking methotrexate were questioned on their knowledge of the regimen and the safety issues surrounding the drug. Of the 93 patients interviewed, all were aware of the weekly dosing regimen. Most patients (72 per cent) were taking oral MTX and of these, 54 per cent were able to state the dose they took in milligrams. A total of 42 per cent knew their dose only as the number of tablets taken each week and 19 per cent did not know the strength of the tablets they took.
"It is important that patients avoid aspirin and alcohol. But only 17 per cent of the patients interviewed knew that they should avoid aspirin," she said. In addition, 65 per cent of the patients did not know of any medicines that they should avoid.
Miss Rippengill gave recommendations for improving safety. These included:
Miss Rippengill commented that patients needed continuous reminders, especially elderly patients who were more likely to forget what they had been told.
In the study, most patients reported that they had been given an information leaflet about MTX but 10 per cent said they had not read it. "Patient’s poor knowledge of their MTX therapy leaves them more vulnerable to adverse effects from prescribing or dispensing errors," she said.
NOEL DIXON, Dixon and Hall, Stanley, County Durham, argued that the responsibility for patients receiving the correct dose of MTX must lie with the pharmacist and prescriber involved in the patient’s care. Miss Rippengill agreed that ultimate responsibility lay with the health professionals but added: "Because errors can and do occur, patient awareness should be increased."
An audience member pointed out that the shape of the 10mg tablet was to be modified early in 2002 and that this would help patients distinguish between the two strengths.
Lack of compliance with therapy cannot explain instability of warfarin- controlled blood anticoagulation, said Dr Dita Engova, academic department of pharmacy, Barts and The London NHS Trust, London.
Dr Engova explained that warfarin treatment is often complicated by fluctuations of the International Normalised Ratio (INR), which is used to express warfarin’s anticoagulant effect. She had therefore conducted a study to identify variables in the stability of blood coagulation and to determine compliance with warfarin treatment.
Patients attending a hospital-based anticoagulation clinic were questioned about their adherence to treatment and their knowledge and beliefs about their treatment. Measurements were taken to determine patients’ cytochrome P450 2C9 polymorphism and plasma albumin and triglyceride levels. Compliance was verified from total plasma levels of warfarin.
Dr Engova explained that data were obtained using three consecutive blood samples, structured interview and a seven-day dietary record. For 41 per cent of patients, INR measurements were outside a standard therapeutic range for two or three of the three measurements. Ninety-nine per cent of patients reported taking warfarin at the same time of day and 95 per cent of patients complied with their warfarin regimen.
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Spring symposium The UKCPA spring symposium will |
"However, compliance was not informed," she said. There was uncertainty among the patients about the benefits of warfarin, with 52 per cent unaware that the drug benefited their health. Patients’ high compliance was attributed to trust in their health care providers.
Dr Engova pointed out that fluctuations of the INR were not caused by interactions between warfarin and other medicines. "Patients who had been taking other medicines for a long time and who had a steady INR would then experience fluctuations even though they continued to take the other medicine," she said.
She conceded that compliance with warfarin seemed to be higher than compliance to some other medicines and that this might have contributed to the fluctuations seen.
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Left to right: Sarah Tulip, Iona Macdonald, Lee-Ann McLaren, Kieran Murphy and Katie Rippengill |
Awards sponsored by GlaxoSmithKline were presented at the symposia for the best oral communications and research posters.
Katie Rippengill, Aston University, received the award for best first-time presenter and Iona Macdonald, Western Infirmary, Glasgow, was best overall presenter. Sarah Tulip, North Durham Healthcare NHS Trust, received the award for best secondary care poster. Kieran Murphy, a locum pharmacist, won the award for best primary care poster.
The Pharmacia preregistration award 2001 was presented to Lee-Ann McLaren, Stirling Royal Infirmary.
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