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Lorna Smalley is medicines management pharmacist
at Greater Derby Primary care Trust and practice pharmacist at
Derwent Valley Medical Practice, Derby
(e-mail lorna.smalley@nhs.net)
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The author at work in her medical practice’s pharmacist-led
hypertension clinic |
In March 2004, I qualified as one of the first cohort of supplementary
prescribing pharmacists from Keele University. I then began working at
Derwent Valley Medical Practice in Derby. However I found myself in a
position where I was qualified to provide a service, but with no framework
of how the service should run. Which patients would be suitable? How
would their agreement be recorded? How should care management plans be
recorded in the patient records? How should repeat prescriptions be managed?
Eight months on, we in the practice have found the answers to many of
our questions. Our pharmacist-led hypertension clinic has evolved into
a successful service that provides evidence-based clinical care within
the legal framework of supplementary prescribing. In this article, I
offer our service as a practical example of how supplementary prescribing
can work successfully in primary care setting.
Preparation
A month before I qualified we started to plan our service. We decided
that we would run a two-hour clinic with 20-minute appointments each
week, initially at our main surgery, and then expanding to a second
clinic to cover our branch surgery. We also developed our care management
plan (CMP) template, which would be adapted for individual patients,
and considered how this document should be attached to patients’ records.
Options included scanning, including a paper copy in the notes and
attaching an electronic copy to the computer record. We chose the third
option.
CMPs must refer to a local or national clinical guideline that the
supplementary prescriber will follow. However, in early 2004, the British
Hypertension
Society updated its guidance, and the National Institute for Clinical
Excellence was about to launch its guidance. With our service due to
go live in early May, which guidance should we include in the CMP? The
answer for us was to write a practice hypertension protocol that would
be based on the current evidence-based national guidance, and updated
upon the publication of new local or national guidance. When further
guidance is issued I simply update our practice protocol accordingly,
rather than amend each patient’s CMP to refer to the new guidance.
Supplementary prescribing is a voluntary agreement between a patient,
a supplementary prescriber and an independent prescriber. We wanted to
provide patients with a written explanation of supplementary prescribing,
ideally before they agreed to participate, to facilitate informed consent.
We chose to adapt the leaflet designed by the College of Pharmacy Practice
Faculty of Prescribing and Medicines Management because it provides a
concise, patient friendly summary of supplementary prescribing.
We also spent time making sure that the entire practice team were aware
of the new clinic, and how we envisaged its operation. We placed posters
in the consulting rooms to inform and remind infrequent prescribers that
supplementary prescribing was operating in our practice. In addition,
we wrote an article for the practice newsletter, shared our start date
with the local non-medical prescribing forum, and contacted local community
pharmacists, detailing the start date, and the area in which I would
be prescribing.
Other preparations including writing my job description, obtaining adequate
indemnity insurance and confirming our understanding of the stepping
stones between qualification and receiving prescription pads. Patient selection
Patients access our clinic via two pathways: computer search or referral
from a member of the clinical team.
We use an EMIS search to identify potential patients. We search for
hypertensive patients and exclude those with other chronic diseases,
since these patients
are already being managed in disease-specific clinics. We also think
it would be inappropriate to ask them to attend multiple clinics within
the practice. We also exclude the elderly, the housebound and those in
residential or nursing home care.
Although this could be considered as making the service inaccessible
to those who may need it most, we thought that it was important to establish
our service and for me to develop my skills as a prescriber in the practice
setting before extending to the wider community. We also believe that
gaining informed consent from some patients within these groups may be
difficult, although we hope to overcome these issues in the future.
We review our list of potential patients and highlight poor attenders,
newly diagnosed hypertensive patients, those with potential compliance
problems and those with uncomplicated hypertension. I then contact my
independent prescriber via an electronic practice note to confirm that
she is happy for me to approach the patient. Practice notes become permanently
linked to a patient’s EMIS record, which provides a clear audit
trail. We have also found them particularly useful because they reduce
the need for contact time with my independent prescriber, which can be
difficult to arrange in a busy practice.
Patients are also referred to me following routine appointments with
GPs or the nursing team. I check the patient’s record and, if I
think that it is appropriate for me to manage their care and I am competent
to do so, I contact my independent prescriber by practice note as above.
More recently, a third pathway has been identified, whereby spouses of
two of our clinic patients have requested that they come along, too. Patient contact and adapting the CMP
Once I have received a practice note confirming that my independent
prescriber is happy for me to proceed, I write to the patient and invite
him or
her to the clinic, usually about two weeks later. The letter is electronically
attached to the EMIS record, again to assist in the audit trail. We
also send a copy of our “Patients’ guide to supplementary
prescribing” to allow the patient to decide whether they want
to participate in the clinic.
We invite three to five new patients each week, depending on clinic
availability. We always leave one or two appointments open for existing
patients requiring
follow up. We have also found that booking new patients into every other
slot helps my time management because, if I overrun, the excess is usually
absorbed by the generally shorter follow-up appointments.
At this stage I merge the CMP template, which is stored on the network
as a word document, with the patient’s EMIS record. This provides
the basis of the patient’s individualised CMP, which I then modify
further, for example, by adding drugs, conditions and guidelines that
I am competent to manage, before dating the CMP to show my agreement
and saving it in the patient’s computer record. I link the entry
to the Read code “hypertension CMP” (8CR4), again for audit
purposes, and send a practice note to my independent prescriber to agree
the CMP, including the date that the patient is due in clinic. My independent
prescriber then dates the CMP, and makes a consultation entry of the
Read code “CMP agreed” (661M) and the condition(s) that I
will be treating. My independent prescriber then returns the practice
note confirming that the agreement is complete. This method of agreeing
CMPs exploits the fact that CMPs require agreement, not signatures, and
is permanently linked to the computer record.
Producing and agreeing the CMP before the patient has agreed could result
in wasted time if the patient did not attend this clinic. However, we
have found that this happens extremely rarely. In addition, having the
CMP prepared and agreed means that I can prescribe during the initial
consultation if necessary. Initial consultation
During the initial consultation I introduce myself to the patient and
explain our reasons for running the clinic. I explain that participation
is voluntary, and can be stopped at any stage if the patient would
prefer. I explain the CMP and that, once a year, we will need to meet
the independent prescriber if my prescribing is to continue. I explain
the frequency of clinics, from weekly to six-monthly. I also explain
that, although patients can see their GP at any time, where possible
they should attend the pharmacist-led hypertension clinic regarding
their blood pressure. I then answer any questions the patient may have,
but I frequently find that by this stage they already have their sleeves
rolled up.
If patients confirm that they are happy to participate, I date the
CMP and record their agreement in the computer record, because there
is not
currently a Read code for patient agreement. In addition, I add a diary
entry to the computer record using the Read code “CMP review” (661N)
to prompt annual review, and add an EMIS major alert stating that the
patient attends my clinic. This alert is displayed when the patient record
is opened, and acts as a reminder to other prescribers of their involvement
in supplementary prescribing. This complete, I then proceed with the
clinical review, write prescriptions, if required, and agree the next
appointment
interval. Repeat prescribing
The practice decided that I should manage my own repeat prescribing.
Although this is not made easy by the fact that I am not yet able to
generate my prescriptions electronically, we believed that it might
not be entirely appropriate for GPs to sign repeat prescriptions for
patients that they may not have seen for several months. If a patient
requires a repeat prescription, I print a repeat slip and write “For
Lorna” underneath the name of the medicine. When this is presented
at reception, it is directed to me and I write the repeat and update
the computer record. This system also allows me to prompt patients
when their review is coming up, by adding a note to their repeat prescription.
If a patient’s repeat prescription contains a medicine that I
am unable to prescribe, I produce an FP10 for those items and attach
my handwritten prescription to it. This method ensures that the patient
is able to collect all their medicines together. Suspending CMPs
Following routine investigations, our clinic has identified one patient
with atrial fibrillation, three with undiagnosed type 2 diabetes, and
two patients who require referral to the urology team. Since these
conditions are outside the terms of the CMP and my competence, we suspended
the CMPs. We removed the major alert and diary entry and add a note
stating “CMP suspended”, having spoken to the patients
to ensure they understand the decision to remove them from the clinic.
Although it is disappointing to lose patients from the clinic, knowing
that I have improved their long-term prognoses gives me a great deal
of professional satisfaction. Clinic statistics
Since starting clinics in May 2004, we have invited 67 patients to
attend, of whom 62 (93 per cent) have attended their first appointment.
Only
two patients (3 per cent) decided not to participate after attending
the clinic, one who found the clinic times difficult, and one who
preferred to see his regular GP. We think that this demonstrates the
acceptability
of our service to patients.
We currently do not routinely chase those who fail to attend the
first consultation, but we write to those patients who have not attended
a
clinic beyond the agreed date. The letter acts as a reminder to those
who have generally forgotten, and also asks those who have intentionally
failed to attend to inform the practice. To date, we have sent six
reminder letters. Two patients have not responded to reminder letters
and have
been removed from our clinic list. Summary
Supplementary prescribing is not about replacing doctors with less
expensive prescribers. Nor is it a quick fix to maximise achievement
of new general
medical services quality indicators. It is about enhancing the quality
of care for patients with chronic diseases. It is time consuming, especially
in the early days as we learn how to manage time and how to target
those patients who would benefit the most. We have experienced problems
with room availability, conflicting guidelines and the developing PCT
infrastructure. However, supplementary prescribing is a long-term investment
in the future of our patients in the hope that we can prevent complications
of chronic diseases.
My experience of supplementary prescribing is that it is a varied and
challenging role that provides a natural extension to the role of the
pharmacist within the health care team.
We have shown that supplementary prescribing is acceptable to patients
and beneficial to the practice. It does not suit all patients or all
diseases, but it does provide another option for forward-thinking practices
and patients to make full use of the pharmacist’s broad skill base. |
The
Pharmaceutical Journal