The Pharmaceutical Journal
Vol 270 No 7230 p26
4 January 2003

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Pharmacist prescribing summary

The direct supply of medicines pilot in Scotland — a local view

Neil Duff, MRPharmS, of Patna Pharmacy in Ayrshire, describes his own experience of prescribing

Neil Duff writes a prescription

Pharmacist prescribing is not new: we have all been counter prescribing for some time. However, in its new form, it has one basic novel element — a prescription pad.

During early 2000, I was approached by the local health trust with a view to piloting a novel project — the "Direct Supply of Medicines" — a Scottish Executive directive aimed at providing easier access to medicines by the general public, greater use of pharmaceutical expertise and freeing general practitioners' time for other issues.

The project was entrusted to two pilot sites — the first in Arbroath, a town of some 30,000 inhabitants, and the second in Patna, a town of some 3,000 inhabitants (see PJ, 23 February 2002, p238). Patna is a self-contained village with one GP practice and one pharmacy. Patients who would take part in the exercise were required to register with the pharmacy and be approved by the GP. For the purpose of the pilot, the patient should normally be exempt from prescription charges, for whatever reason.

The project, initially intended to begin in late 2000, finally got under way in April 2001 after a three-month baseline gathering phase by the evaluators, Scottish Health Feedback.

Formulary

A formulary had been drawn up based on those products which were normally prescribed by the practice for "common ailments". This covered some 11 therapeutic areas and had limiting criteria for prescribing, advice only and referrals. The formulary was determined over many months by our pilot committee which included one GP, who keenly supported the project, the trust's senior pharmaceutical adviser, the manager of the local health care co-operative, a representative from the school of pharmacy at Strathclyde University, the practice managers and myself as community pharmacist. A list of prescribable medicines, based on presenting symptoms, length of treatment ,criteria for referrals, limitations and exclusions was laid down. The formulary in Arbroath was determined independently although, in reality, there were only minor variations. The Prescription Pricing Department was informed of all prescribable items. And so we began ...

My great concern was that at 9am on 1 April 2001, patients would be queuing around the block — how would we cope the deluge? All this was unfounded. After a slow start registration of patients reached only about 25 per cent of the target group, which at the time was a surprise, although on reflection the trigger for applying to such a novel scheme would be some immediate illness and not the possibility of one. Registrations have continued beyond the pilot phase and are still growing steadily. The main patient participants in the pilot have been children (or their concerned parents) presenting with teething pains, cold symptoms and fevers, and head lice infestation. Diarrhoea, constipation, aches and pains, coughs and colds have been the main presenting symptoms among adults. All therapeutic areas have been visited during the period.

During the pilot study, no domiciliary visits were undertaken. Only those patients presenting in the pharmacy were counselled or given prescriptions.

Some early problems were encountered, for example, with products such as cetirizine, loratadine, paracetamol and ibuprofen which were P medicines only in their counter packs and POMs in larger quantities. To overcome this, patient group directions allowed us to prescribe, for example, a 30-day course of antihistamines during the hay fever season. A prescription for a seven-day course would need the patient to return to the pharmacy every week or visit the GP for a larger quantity, which the pilot was designed to avoid.

All prescriptions were handwritten — no software yet! — on a specially designed prescription form (a CP1), which is light green and differs from the standard GP10 in that the participating pharmacist is identified by his or her Royal Pharmaceutical Society registration number in addition to the GP number. The patient's community health index (CHI) number was also recorded.

Payment for the pilot was made from money made available by the Scottish Executive paid quarterly on a per capita basis. Reimbursement of drug costs was extracted from normal submissions to the PPD and paid monthly.

All details of every intervention (including CHI number, exemption status, symptoms, treatment, medication strength and quantity, advice given, and whether the patient was referred) were relayed to the evaluators. (Their report is shortly to be published.) Early reports are encouraging and costs were found to be low.

The pilot has been well received by patients and, although a solid core of them has used the facility more than others, there has been no evidence of abuse. Our formulary categories were written with enough safeguards to prevent continual prescribing to the same patients presenting with the same problems. During the study several points became apparent, certainly with a view to future roll-out and longer-term development:

• The pharmacy would require a private consultation area

• A second pharmacist would be desirable to cover busier periods and holiday continuity

• A national "pharmacist prescriber" formulary would be essential

• A registry of patients must be maintained at a central source, especially if professional payments are to be on a per capita basis

The future

Certainly we are in the early stages, but the pilot has evidently been successful enough to warrant a controlled roll-out , bringing in other pharmacies in larger urban areas and finally in cities. This phased roll-out will follow the timetable laid down within the Scottish "Right medicine" document and, it is hoped, will run in conjunction with the other roles currently being discussed, namely supplementary prescribing and medicine reviews. There may be problems along the way but these will be surmountable. Maybe, by 2004/05, all pharmacists will wear a prescriber's hat.

Pharmacists have been under-recognised , under-used and under-valued for as long as I can remember, but the drums are beating. Can we follow the rhythm?