The Pharmaceutical Journal
Vol 274 No 7353 p710
11 June 2005

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Laying the groundwork for independent prescribing in paediatric oncology

Supplementary prescribing, cancer care and children’s health are all high on the Government’s health agenda. Sue Marsh combines these by prescribing in the paediatric oncology clinic at a Coventry hospital. Dawn Connelly (on the staff of The Journal) finds out how her role developed and what the future holds

Vision for pharmacy series

Since Sue Marsh became an integral member of the multidisciplinary paediatric oncology team at University Hospitals Coventry and Warwickshire NHS Trust, the number of prescriptions requiring pharmacy intervention has gone from 50 per cent to almost zero.

Ms Marsh is lead pharmacist for cancer services at the trust and has been working as an oncology pharmacist there for the past nine years. In 2001, a snapshot intervention audit of oncology prescriptions confirmed what she suspected: pharmacy staff were intervening on 50 per cent of paediatric oncology prescriptions and on 30 per cent of carboplatin prescriptions. “We decided to get more involved in those two areas of prescribing to see if we could reduce the time we spent intervening and to reduce risks to patients,” explained Ms Marsh.

Clinic model

Four years on and Ms Marsh is reviewing and preparing prescriptions for all paediatric oncology patients. Although she is trained as a supplementary prescriber, and carries out this role in the adult oncology clinic, she finds that it is not practical in the paediatric clinic. Part of the problem is the lack of space. The clinic has a waiting room and one consulting room — this means that it would be impossible for Ms Marsh to have private consultations with patients in the clinic. Another problem is the wide variety of drugs prescribed for young patients — it would be difficult to write clinical management plans to cover all scenarios.

The model that Ms Marsh has developed seems to suit all those involved. On the morning of the clinic, she checks each listed patient’s medical notes to determine if he or she is due for chemotherapy and what regimen needs to be prescribed (99 per cent of prescriptions are written in accordance with UK trial protocols and the rest according to protocols specified by Birmingham Children’s Hospital where the patients’ cancers are diagnosed). She then writes prescriptions in advance of the clinic so that chemotherapy and oral medicines are ready to be administered. The consultant signs the prescription once he agrees that it is appropriate to proceed. “It means that I can prescribe anything rather than be limited to what would be on a clinical management plan,” she explains. She adds that the training she received as a supplementary prescriber has made her more aware of the whole patient pathway.

Ms Marsh plays an active part in the patient consultation process. A paediatric oncologist, a haematologist and Ms Marsh jointly review the patient, decide whether he or she can go ahead with chemotherapy and address any problems. “Because it is a multidisciplinary clinic, there is no requirement to push for supplementary prescribing,” she says. Ms Marsh believes that the ideal scenario in this particular clinic would be for her to be an independent prescriber. “I am planning to train as an independent prescriber, but a lot depends on the criteria. Some of the options that have been put out for consultation, such as a limited list, wouldn’t work at all. We would then have to look at the supplementary prescribing role in a lot more detail — I would be disappointed if that option were taken forward.”

Ms Marsh would like to see pharmacists permitted to prescribe anything provided it is within their clinical area of expertise. In addition, she believes that her role should meet the criteria specified for consultant pharmacists and this is also something she plans to work towards.

Reluctant

To begin with, the paediatric consultant was a little reluctant to accept that a pharmacist wanted to be part of the clinic, but, with patient numbers rising from 500 to 1,500 over the past three years, having Ms Marsh in the clinic allows more patients to be seen in the same amount of time. The clinic staff quickly saw the benefits, she says. “The consultants are less pressured and can concentrate on reviewing patients,” says Ms Marsh. She adds that one of the other oncology consultants in the trust is now acting as mentor to a pharmacist who is training as a supplementary prescriber.

Patient benefits

Ms Marsh spends a lot of time discussing drug therapy with patients and their carers. She explains that chemotherapy regimens are often complicated and it is sometimes hard for parents to take it all in. “I get to know the patients and their families, and this helps me know what to do, in terms of their medicines, to make their life easier,” she says. Other patient benefits include shorter waiting times — dispensing times have decreased from more than an hour to 30 minutes — and a reduced risk of chemotherapy being prescribed incorrectly.

The oncology nurses are also pleased with the service. “The nurses can speak to someone at any time during the week when the consultant is not available,” Ms Marsh explains. Equally, pharmacy dispensary and production staff are able to direct queries to Ms Marsh at any time.

Future developments

More and more chemotherapy drugs are becoming available orally and this prompted the idea of setting up a pharmacist/nurse-led oral chemotherapy review clinic. “There seems to be a notion that giving patients oral therapy is easier and safer. I have a real worry about oral chemotherapy, particularly when patients aren’t taking it on a daily basis,” says Ms Marsh.

She is also concerned that if those taking oral therapy do not attend a regular clinic they will miss out on support gained through interaction with other cancer patients. She hopes to get the clinic up and running within the next six months.

Ms Marsh clearly loves her job. “I love working closely with the clinicians and being viewed as an equal, and I love getting to know the patients better because I feel that I am actually making a difference.” She was surprised that there were only four hospital pharmacists out of 30 on her supplementary prescribing course. “I can’t understand why there aren’t more hospital pharmacists out there grasping the opportunities,” she admits.