Pharmacist prescribing: Pharmacist prescribing works in practice
Prescribing by pharmacists in different care settings and improving
out-of-hours services were discussed at a session on 15 September. Clare
Bellingham (on the staff of The Journal) reports
With supplementary prescribing about to become a reality, this session
looked at different situations where pharmacists already, or could, prescribe.
How out-of-hours services have been improved in Blackpool Primary Care
Trust was described by Magnus Hird, its head of prescribing. Fylde Coast
Medical Services (FCMS) was set up in 1994 and provides both an out-of-hours
service and an in-hours telephone answering service. “Internal
audits identified that 40 per cent of the out-of-hours case load dealt
with minor ailments,” explained Mr Hird. So a bid was approved
for a new out of hours service to deal with these calls which is operated
through a local pharmaceutical service (LPS) contract. It began in May
this year.
Most patients access the service by telephone. Telephone calls are answered
by a trained operator (who is not a health care professional) who allocates
the call to one of four categories. These are an emergency ambulance
call (blue calls), a general practitioner to call back within an hour
(red calls), a general practitioner to call back within two hours (amber
calls) and a fourth less serious category (green calls).
Patients in the green category are now referred into the LPS service.
Previously they would have been telephoned by a GP within six hours.
Instead, they could be called by a pharmacist or nurse. The aim is to
reduce the GP workload.
“The pharmacist can decide if they want to issue a medicine and
can request a prescription from a GP,” said Mr Hird. “This
demonstrates that pharmacists can act as independent prescribers; we
are almost there.”
Data from June shows that pharmacists are now taking about 20 per cent
of the calls received by FCMS, explained Mr Hird. “Pharmacists
complete 88 per cent of the calls they are allocated; 12 per cent are
referred back to a GP.” A reduction in GP hours has occurred, of
14 hours per week.
Asked if patient group directions (PGDs) could be used rather than LPS
or prescribing rights, Mr Hird said that it would be possible but not
ideal. A large number of PGDs would be needed for each situation. In
addition, supplementary prescribing would not be useful for acute situations
so independent prescribing rights would be the best approach.
Lindsay Harper: think radically about services |
Meanwhile at Hope Hospital in Salford, Kirstine Farrer, a dietitian,
and Lindsay Harper, a pharmacist, have introduced new ways of providing
patients’ total parenteral nutrition requirements.
Both attended training courses before expanding their roles. In addition,
consultants who were the traditional prescribers assessed interventions
under the new ways of working using a specially developed scoring system.
An evaluation of 22 patients’ notes has been completed. “None
of our 181 interventions has had a detrimental effect on patient care,” said
Ms Harper. A “very significant positive impact” was observed
in 7 per cent of interventions, a “significant positive impact” in
53 per cent and a “positive impact”, seen as part of routine
care, was seen in 40 per cent.
Ms Harper said people should think radically when designing services
and challenge traditional ways of working. “Good communication
is needed, and people need to take responsibility for their actions.
If we found something that was beyond our capability we asked the consultant
for help. This built a good relationship with the traditional prescribers
and has meant that our roles are expanding further.” She added: “This
proves that appropriately trained dietitians and pharmacists can prescribe
parenteral nutrition without the need for routine medical intervention.”
Maurice Hickey: a step down the road |
Community pharmacy
Maurice Hickey, a community pharmacist in Forres, Morayshire, is one
of the first pharmacists to be undertaking supplementary prescribing
training. “To me it seems like a natural extension of my job,
to be able to start to manage patients’ medicines properly,” he
said. “If we are truly to manage their medicines then we must
have the ability to change their medicines.”
Mr Hickey explained that in the short-term there had been a considerable
expansion in his workload. “The course is not easy, but then you
would not want it to be otherwise it would be worthless,” he said.
Mr Hickey plans to use his skills to manage patients with asthma and
chronic obstructive pulmonary disease. Other pharmacists on his course
will be prescribing for endocrine, gastrointestinal or cardiovascular
conditions. “Once we have learnt the basic skills then we could
extend our prescribing to other therapeutic areas,” he suggested. “Eventually
I would like to run a pharmacist-led pain relief clinic.” He added: “I
see this as a step down the road that will lead to independent prescribing.”
Some controversy was raised over the area of practice that pharmacists
wanting to become prescribers work in. One participant suggested that
there was a feeling that community pharmacists are too busy to take on
the role. Mr Hickey disputed this, saying that changes in practice such
as use of accredited technicians would help to free pharmacists’ time.
Mr Hickey is undertaking his training at the Robert Gordon University
in Aberdeen. Of the 40 pharmacists in the first cohort, 27 are community
pharmacists. This contrasted with the situation at King’s College
London where only three of the first of 25 students are community pharmacists.
However, Gul Root, principal pharmacist, Department of Health, said that
on other courses in England there were more community pharmacists. “Ministers
are keen that there are community pharmacists on the first cohort of
courses,” she stressed.
Remuneration for supplementary prescribing was also an issue. Bill Scott,
chief pharmaceutical officer for Scotland, commented: “I would
not see pharmacists being paid separately for prescribing but would see
it as part of practice. We need to change the way pharmacists are paid.” This
was backed by Frank Owens, chairman of the Scottish Pharmaceutical General
Council, who sits on the other side of the negotiating table for a new
pharmacy contract. He stressed that all pharmacies in Scotland should
provide the same services.
Linda Collins, pharmaceutical adviser at Cherwell Vale PCT, said: “If
there is a clear service need, such as for out-of-hours services, then
it is relatively easy to find money. It is important to have supplementary
prescribing in community pharmacy but the difficulty is turning it into
a service need.”
Several delegates raised concerns over the need for professional indemnity
insurance for pharmacists taking on prescribing roles. Both Ms Harper
and all pharmacists involved in the FCMS service had needed additional
insurance.
Collette McCreedy of the National Pharmaceutical Association said: “At
the moment our policy is to ask members to write to let us know they
are involved in supplementary prescribing so we can keep an eye on how
practice is developing.
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