The Pharmaceutical Journal
Vol 274 No 7347 p513
30 April 2005

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Supplementary prescribing: one year on

It is a year since the first pharmacist wrote a supplementary prescription. A group of supplementary prescribers met in London on 11 April to discuss the challenges they have faced. Clare Bellingham reports

Awareness of supplementary prescribing is lacking. It is not just the public who do not understand the concept of supplementary prescribing; it is also a mystery to some health professionals. This is one of the problems that was identified by a group of supplementary prescribers who met at the Royal Pharmaceutical Society last week.

It is a year since the first pharmacist wrote a supplementary prescription, and last week’s conference was organised by the Society to assess how supplementary prescribing is working in practice. The answer is that it is working in some places but facing hurdles in others. However, most seem to think that these challenges are not insurmountable.

“By the end of the decade, there will be more non-medical prescribers than medical prescribers. It is an absolute revolution,” says Clive Jackson, chief executive of the National Prescribing Centre. But it is important to resolve the issues identified by the early supplementary prescribers.

Issues the group identified are summarised in Panel 1. The reason behind the lack of awareness of supplementary prescribing, mentioned above, provoked debate. Some participants thought that clinicians’ lack of awareness is down to the fact that the supplementary prescribing model is too complicated: they simply do not understand how it works. Others thought that pharmacy bodies and the Department of Health have failed to promote supplementary prescribing. One interesting problem within this issue is a lack of awareness among other pharmacists. Examples were quoted of community pharmacists refusing to dispense other pharmacists’ prescriptions because they were unclear about their legality.

However, increasing awareness of the role has to be balanced against a recognition of its limitations. The key is to find a way to incorporate supplementary prescribing into existing practice so that it improves patient care. As Karen Acott, pharmacist prescriber at Wallingbrook Health Centre in Chumleigh, Devon, says: “I had to identify the values I could bring to augment what the practice nurse was already doing.” There would have been little point in setting up a clinic in a therapeutic area if the nurse had already done so.

Anxieties were plentiful around clinical management plans (CMPs). Many participants thought they were time-consuming and cumbersome. One particular problem is their use in patients with co-morbidities. Helen Williams, supplementary prescriber for the heart failure service at King’s College Hospital, London, explains that the CMP has to be broad to allow efficient practice. But questions remain. For example, since non-steroidal anti-inflammatory drugs can have an impact on heart failure, should pain control be included in the CMP for heart failure? And how should a supplementary prescriber treat a patient’s request for a treatment for a completely separate minor ailment?

Many participants were concerned about training, not just the initial training but also ongoing support following qualification. Comments such as “there is a need to ensure the pharmacist is competent, and remains competent, in the therapeutic area of prescribing” were common.

Funding was an issue but was lower down many participants’ list of concerns than might have been predicted. However, worries about accessing prescribing budgets, funding training time, hikes in indemnity insurance and paying mentors, as well as funding the prescribing clinics themselves, certainly featured.

IT was also a concern. One problem is that GP computer systems do not support supplementary prescribing. Mahesh Sodha, a community pharmacist supplementary prescriber in Chelmsford, explains that supplementary prescribers have to hand-write prescriptions and then add them to the patient’s electronic record afterwards. “If I print a repeat prescription, I cannot sign it even if it was me that initiated the drug in the first place,” he says. Another big issue is that some pharmacists still do not have access to patients’ medical records.

Many of the supplementary prescribers present had found innovative ways around the issues outlined above. But it is worth noting that of 45 qualified supplementary prescribers present, one-third were not currently practising as prescribers.

Among their recommendations, two themes came to the fore: the need to increase awareness of supplementary prescribing and to find a way to provide ongoing support to supplementary prescribers. The key recommendations are given in Panel 2.

Speaking at the conference, Gul Root, principal pharmaceutical officer at the Department of Health, clarified a number of the prescribers’ concerns. She explained that there is no need for patients to provide written consent to be managed under a CMP; recording in a patient’s notes their verbal agreement is sufficient. In addition, a CMP could state that drug choice should be based on local or national guidelines, or the BNF.

Mrs Root also said that workforce directorates of strategic health authorities can make local decisions on how to spend the budgets they are given for supplementary prescribing, provided that an expected number of nurses and pharmacists are trained. The SHA could choose to fund a mentor’s time or to make a contribution towards locum costs to cover a pharmacist’s training time. She added that SHAs would not be able to afford to pay all mentors or cover all locum costs.

Finally, Mrs Root expressed a desire to see more community pharmacists becoming supplementary prescribers. On this point, it is worth noting the impact of devolution. Gill Hawksworth, Society past-president, said that there has been a greater focus on developing supplementary prescribing in community pharmacy in Scotland than in England.

For pharmacists to develop their role as supplementary prescribers, they need to identify their unique selling point. Mrs Acott says that it is clear that this is expertise in medicines. Focusing on this, she has set up medicines review clinics in which she uses supplementary prescribing for all patients, adding bite-sized CMPs to patients’ notes as appropriate. Similarly at King’s, Ms Williams and the heart failure nurse divide the roles within the clinic so that Ms Williams largely concentrates on medicines management. These cutting-edge pharmacists show how supplementary prescribing can move forward: it is up to the profession and the Government to act on their recommendations.