The Pharmaceutical Journal
Vol 271 No 7260 p144
2 August 2003

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Supplementary prescribing in practice

By the end of this year, some pharmacists will be supplementary prescribers. Clare Bellingham (on the staff of The Journal) talks to a pharmacist who has undertaken a pilot of the clinical management plan template that has been designed for use by supplementary prescribers

Related websites
Supplementary prescribing: the Clinical Management Plan (more)

Supplementary prescribing is just around the corner for pharmacy. But, as with any new way of working, uncertainties still exist over exactly how it will work in practice. One such area is the use of clinical management plans.

The idea is that, for each patient, a clinical management plan will be drawn up by the independent prescriber (doctor or dentist), the supplementary prescriber (pharmacist or nurse) and the patient. It will set out how the patient will be managed and what the supplementary prescriber's responsibilities are. It includes when the dose, frequency or formulation of a medicine can be changed, when the patient has to be referred back to the independent prescriber and when the plan has to be reviewed.

Two template clinical management plans are available on the Department of Health's website. One is for situations when all the health professionals involved have access to the same patient records (referred to as "full co-terminous access") and the other is for when they do not.

One of the first pharmacists to find out how clinical management plans work is Dr Nuttan Tanna, a specialist pharmacist for menopause and osteoporosis at the Northwick Park menopause clinical and research unit, North West London Hospitals NHS Trust. She was asked by the Department of Health to pilot the template clinical management plan for shared access to the same patient record (something she already had).

The pilot had two objectives: first, to provide the information required by the Department of Health and, second, to allow the team at the hospital to gain a better understanding of how supplementary prescribing by a pharmacist would work in practice. This would help the clinic to decide whether or not Dr Tanna should undertake the necessary training to become a supplementary prescriber.

Menopause clinic

Dr Tanna has been running a medicines management clinic for menopause and osteoporosis for over two years. The majority of patients are referred to the menopause clinic by general practitioners. Initially, referral letters are screened to determine if the patient appears to have a medicine-related or a clinical problem. "If it is a medication issue, they will be put on my list, or on the consultant's list if it is a clinical issue. In some cases, patients will be put on both lists," Dr Tanna explains.

In each clinic, Dr Tanna will see four patients for a 45-minute medication review and two patients for shorter follow-up consultations. She will address any issues in the pharmaceutical care of the patient — not just those specifically connected with the menopause. During the pilot, Dr Tanna developed a clinical management plan for the patient using the DoH template as well as carrying out a medication review. "At the consultation, I could identify which patients I could manage as a supplementary prescriber," she says. The pilot lasted for two weeks, and five of the 11 patients referred to Dr Tanna could be safely managed by a pharmacist working as a supplementary prescriber.

Responsibility for writing the clinical management plan fell to Dr Tanna. "I agree the clinical management plan in the one-to-one consultation with the patient, and the decisions are all evidence-based," she says. She has worked with the rest of the clinic team for a considerable time which has given them confidence in her decisions.

The patient's input is important. "For example, a patient might have three different treatments to choose from depending on the sort of risk/benefit the patient wants to take. So I would ask them how they feel about the risk and about their lifestyle and together we would agree a plan." Dr Tanna then discusses the plan with the consultant. Have there ever been any disagreements? "I've never had a problem to date," she says. The final clinical management plan is also sent to the patient's general practitioner.

A number of issues have arisen from writing a clinical management plan for the five patients. First, the duration of the plan can vary: it can last anything from two months to four or five years. Second, what the plan covers can vary. One plan can cover two or three different clinical issues. And it can be specific to either a drug or a therapeutic area. "I had a mixture of both: two were drug-specific, three were therapeutic area-specific," says Dr Tanna. Three patients seen in the clinic required multidisciplinary management. "Supplementary prescribers have to think about multidisciplinary issues, not just about drugs. These issues run side by side with drug-related problems," she comments. Finally, when writing a plan it is important to consider the protocols and the evidence base.

In Dr Tanna's case, all the patients had some symptoms of menopause to be managed on the clinical management plan.
Several were given hormone replacement therapy, one required a tapering of HRT dose before stopping it entirely. Another required a trial of antidepressants to see if it improved menopause symptoms and libido because HRT was contraindicated.

Objectives met

The first objective of the pilot was to test the clinical management plan template for the Department of Health. "We found it to be user-friendly and comprehensive. We suggested only one modification," says Dr Tanna. This is the addition of a table at the bottom of the page to provide quick access to a summary of the information gained at the first consultation.

But how would supplementary prescribing by a pharmacist work in practice? Does the team think that a pharmacist prescriber is a good idea? On the whole, the answer is yes. No problem exists with the clinical management plan. However, the pilot did raise some questions over practical issues. "If I become a supplementary prescriber then I will need to have a service level agreement with primary care practitioners," Dr Tanna says. "At the moment the menopause clinic receives a block payment for the first appointment and two follow-up visits. A new service level agreement would be needed according to what is in the clinical management plan."

Another issue is that the clinical management plans often lasted for four or five years. "There is an issue over whether I should hold on to patients for this long in secondary care," says Dr Tanna. So she is now looking at the possibility of running a menopause and osteoporosis medicines management clinic in primary care.

Not only has the pilot proved that the clinical management plan template works, it is a ringing endorsement for supplementary prescribing too.

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