| I am training to become a supplementary prescriber and among many lessons
I am learning, the key one is about developing the right approach to
prescribing.
I have reflected on what may be the differences between the pharmacist’s
typical role and that of a supplementary prescriber. My conclusion is
that the distinguishing difference is the change from prescription monitoring
to patient monitoring. Let me illustrate this point with an example.
Pharmacists will be familiar with prescriptions for digoxin used for
the control of atrial fibrillation (AF). Assessment of a prescription
for digoxin can take many forms, depending on the needs of the patient,
location of the consultation and availability of information. One may
ask patients if they have had digoxin before and for how long, if they
are experiencing any problems, whether they are taking any other medicines,
being vigilant for the possibility of drug-drug and drug-patient interactions.
In hospital practice, one may decide to estimate a drug level, checking
the indication, and if there are suspicions of toxicity or lack of effect,
request a blood level, giving appropriate instructions regarding sampling
times. Any or all of the above constitutes pharmaceutical monitoring
for digoxin.
So what is different for the supplementary prescribing pharmacist? The
clinical scenario may be similar. If the clinical management plan (CMP)
states that digoxin is to be prescribed for treatment of AF, what does
the pharmacist supplementary prescriber have to monitor? In addition
to the above, it is an assessment of the therapeutic response to ensure
the prescription is still appropriate that distinguishes routine monitoring
from that undertaken by a pharmacist prescriber.
I expect that most of us do not monitor a patient’s radial pulse,
although we may look at the rate recorded by other health care workers.
We are unlikely to listen to the apical rate. Many of us may not know
what AF feels like (in a pulse) and would not be confident to read AF
from an electrocardiograph.
The question is, what additional monitoring must we do to prescribe safely?
As prescribers, we are bound to confirm the current clinical condition
of the patient, before we represcribe. The line between monitoring and
diagnostic skills depends on the agreement between the supplementary
and independent prescriber, which in turn will depend on the nature of
the relationship between the two prescribers. What we must do is to confirm
that the condition we are treating still requires the treatment we offer.
Since the publication of the National
Service Framework for Older People in 2001,
pharmacists have received multidisciplinary recognition for their role in the
management of medicines for older people.
Medication review by pharmacists is now an established service within many GP
practices and could, I believe be further strengthened through supplementary
prescribing. The role of supplementary prescribers for older people will vary
according to the level of access by patients to nursing and pharmacy services.
Patients attending GP practices, community pharmacies and those living in nursing
or residential homes could all benefit from supplementary prescribing.
Medication review clinics in GP practices already exist and are certainly an
excellent place for supplementary prescribing to take place. GPs may refer patients
directly to the pharmacist, patients may self-refer or pharmacists may select
patients from their records and offer an opportunity for medication review. Nurse-led
clinics based in GP practices for asthma and diabetes are good models for pharmacists
to use to develop new clinics or change their existing clinics.
The community pharmacy setting is ideal for piloting the viability of shared
patient records and supplementary prescribing. LPS pilot schemes for medication
review may lead to supplementary prescribing partnerships, based in community
pharmacies with suitable premises.
Most care homes do not link with a single GP, but the ones that do are likely
to be among the first to benefit from supplementary prescribing. Once the benefits
of a CMP-based system have been demonstrated, other homes with a number of GPs
should be able to implement supplementary prescribing. The success of these schemes
will depend on reliable, rapid access to shared patient records (ideally electronic),
regularly reviewed CMPs and effective communication between independent and supplementary
prescribers and other members of the health and social care team.
So what have I been doing? I have been working on areas for CMPs with my medical
mentor in order to institute supplementary prescribing in a 30-bed nursing home.
We intend to produce web-based outlines for each disease process that we commonly
see in our patients. These outlines will be downloaded and individualised to
create a patient-specific CMP. Web technology is critical to us, as we intend
to use available guidelines to support prescribing and these can be accessed
by web links. It is clear to us that the supplementary prescribing course is
just the start of the journey. The list of dis-ease areas for inclusion in our
CMPs will take us about two years to complete.
What about the hospital sector? The hospital outpatient department already accommodates
many examples of pharmacist-led clinics, including preoperative, anticoagulation,
lithium- and clozapine- monitoring clinics, and these are all being explored
as supplementary prescribing opportunities. Many of the patients seen will be
older, but there are few pharmacist clinics dedicated to the older person. This
is an area that should be explored, because there may be clear opportunities
for patients who regularly attend care of older people clinics (or specific disease-related
clinics) to benefit from supplementary prescribing. Hospital wards may be a more
problematic for supplementary prescribing owing to the rapid patient turnover,
but rehabilitation or intermediate care settings could adopt the nursing home
model, in which CMP outlines are available to efficiently produce individualised
CMPs.
As with all new roles, supplementary prescribing is likely to be seen a challenge
to the traditional practices of other disciplines. We must be confident in what
we can do and firm about that which we cannot do. Our role will develop, and
the scope of practice of each supplementary prescriber may increase as skills
and confidence increase. We must remember that this is individual to the prescriber,
and ensure our colleagues do not view supplementary prescribing as a generic
function.
We also have a lot of explaining to do. Patients, carers and health professionals
alike are not aware of supplementary prescribing and we will have to be ambassadors
for the role until it becomes understood. But I am confident that supplementary
prescribing will promote pharmacists as champions of medicines management for
older people.
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