The Pharmaceutical Journal
Vol 273 No 7319 p482
2 October 2004

This article
Reprint   Photocopy

PDF 410K, Acrobat Reader

Where the future lies for prescribers

The 2004 British Pharmaceutical Conference and Exhibition “ Medicines: from cell to society” took place at Manchester International Convention Centre from 27–29 September

BPC 2004 summary

Community pharmacies offer a particular advantage as a location for pharmacist prescribers because of their long opening hours, explained Ashok Soni, chairman of the National Pharmaceutical Association and a supplementary prescriber. “Our local surgery is open approximately 20 hours a week whereas the average community pharmacy is open for 60 to 70 hours a week,” he said. The pharmacy could be a different point of access. “This provides patients with an opportunity to access services at a time that suits them.”

Turning to the profession itself, he said that as supplementary prescribers community pharmacists are more integrated in the health care team. Opportunities for prescribing pharmacists include managing long-term conditions, negotiating with patients so that they become more compliant and reducing adverse drug reactions.

However, there are some threats, too. First is the lack of access to patients’ records in community pharmacy. “There is a real need to put pressure on central Government to allow pharmacists greater access to patients’ medical histories,” he said. Another threat is potential conflict between pharmacists, doctors and patients, such as lack of trust or disagreements. Time constraints also pose a threat to supplementary prescribing.

Commenting on the issue of whether pharmacists should be generalists or specialists, Mr Soni said that community pharmacists need to be generalists. “There is no point in a patient having to go to one pharmacy for one thing and another pharmacy down the road for something else,” he explained.

Primary/secondary care interface

Pharmacists interact with patients in hospital but the problem is what happens before and what happens after, said Duncan McRobbie, principal clinical pharmacist at Guy’s and St Thomas’ Hospital NHS Trust, London. Two and a half years ago, a local GP surgery approached him about setting up a clinic to improve continuity of care. The clinic’s roles include tackling sub-optimal management of ischaemic heart disease, heart failure, hypertension and atrial fibrillation. The clinic takes referrals from GPs and reviews patients on the surgery’s coronary heart disease register. Mr McRobbie deals with repeat prescriptions, suggesting new medicines or dose adjustments in 20 per cent of cases and discontinuing unnecessary medicines in 15 per cent.

When supplementary prescribing was introduced, the clinic team, GPs and hospital consultant drew up clinical management plans for pharmacist prescribers. “We have done some work to assess the appropriateness of the pharmacist’s prescribing,” said Mr McRobbie. “The data show a trend towards better prescribing in terms of appropriateness of what is prescribed and monitoring of its safety and efficacy.”

Mr McRobbie said that one of the benefits of the clinic is that it allows trained expertise to be brought into the GP practice. Dealing with patients with CHD is only a small part of a GP’s total workload, but it is Mr McRobbie’s specialist area. Another benefit is that it provides him with the opportunity to follow up patients he has seen in the clinic when they are admitted to hospital and vice versa. In terms of difficulties, he said having to hand-write prescriptions is a backwards step.

He concluded that with a trained pool of pharmacists in community and hospital pharmacy there seems to be competition over who should be carrying out roles such as his. “PCTs should take an overall look and decide who is best to provide each service. It should not be a case of services being provided only by hospital pharmacists or only by community pharmacists,” he said.

Success but issues remain

Anne Lovejoy, lecturer in pharmacy practice at King’s College, London, reported the experiences of some of the pharmacists who undertook supplementary prescribing training at King’s. Altogether, 59 per cent of the students were hospital pharmacists and the remainder were evenly split between primary care pharmacy and community pharmacy. “Most qualified in the spring so services are only just getting going now,” she said.

Those who have started prescribing are doing an exemplary job, said Ms Lovejoy. “Hospital pharmacists have been leading out-patient clinics. Two clinics are for heart failure and, since they began, the number of re-admissions has reduced so these clinics are improving patient services,” she said. Other clinical areas in which hospital pharmacists are prescribing include critical care, HIV, coronary heart disease and oncology. But in primary care, many of the services have yet to start although plans are in place for medicines management clinics in areas such as diabetes, epilepsy and arthritis.

Ms Lovejoy explained that in the acute sector, clinics have been working on the edge of the legislation for a number of years but that this means that supplementary prescribing could be added relatively easily. “In primary care, it is a little different,” she said. “PCTs are reticent and nervous about supplementary prescribers.” Not only are PCTs concerned about clinical governance responsibilities arising from supplementary prescribing but they are also anxious about other issues, such as additional prescribers ruining their prescribing budgets.

“ So of the 13 community pharmacists who undertook the King’s course, only two have got a service funded,” she said. Despite this, she commented: “We have to start somewhere and not be put off by these problems.”

For this new scope of practice to succeed, pharmacists will have to work with other health care professionals, health organisations and patients. “We have no idea how patients will respond to other types of prescriber,” she commented. A success of the clinical management plan used in supplementary prescribing is that it had forced health professionals to work in a team with each other and patients, she said.