| When new money to enable community pharmacists to set up supplementary
prescribing clinics was announced in Scotland a few weeks ago (PJ, 16
July, p73), it marked a turning point. Those community pharmacists who
had so far struggled to use their supplementary prescribing qualification
jumped into action. Some have already managed to get clinics up and running
and other clinics will start in the coming weeks.
Chief Pharmaceutical Officer in Scotland, Bill Scott, explains: “We
were very aware that after pharmacists had qualified as supplementary
prescribers, unless they were using those skills, they would probably
lose them. So I was keen to put the message out that we wanted to encourage
pharmacists to use those skills.” But why the funding for community
pharmacy? “If you look at the pharmacy workforce in Scotland, 90
per cent works in community pharmacy. For most of the people living in
Scotland, their experience of pharmacy is with a community
pharmacist.”
The funding does more than allow community pharmacists to set up clinics:
it also aims to find the best way to use supplementary prescribing. “There
is an element of allowing pharmacists to have a blank sheet of paper,” Mr
Scott comments. “It is early days for these new powers and it will
take some time to work out how to use them in the optimal way.”
Although there are similarities between the clinics that have been set
up so far, there are also some differences. One major difference is the
type of patients that are being targeted: some pharmacists are opting
for long-term monitoring of stable patients while others are intensively
managing patients with complex needs. Mr Scott says there is room for
both models.
Jonathan Burton is targeting patients with asthma for his supplementary
prescribing clinics at Campus Pharmacy at Stirling University. “Asthma
and depression are the only two chronic diseases we see a lot of within
our young population,” he explains. “Although I am concentrating
on asthma, I have added allergic rhinitis and smoking cessation to my
areas of competence for supplementary prescribing.”
Running asthma clinics at Stirling University
campus
 At Campus Pharmacy at Stirling University, Jonathan Burton (pictured)
is setting up a supplementary prescribing clinic for asthma patients.
He will launch the service at the start of the new term in mid-September.
Patient sign-up will be done by local GPs. The GPs will offer the
service during patients’ appointments and they will have pre-prepared
clinical management plans on hand. Mr Burton’s CMPs will include
steps 1 to 3 of the British Thoracic Society guidelines. “I
discussed with the surgery where the gaps in the system are, and
it is not with patients in steps 4 or 5 of the BTS guidelines — they
are well monitored. The gaps are with those patients in step 1 or
bordering on step 2, patients who are often not good at attending
clinics at the surgery but who come to the pharmacy regularly for
their inhalers,” he comments. “I will start with a reasonably
small number of patients — say half a dozen — for the
first couple of months. We will then expand once we have checked
to see that it works,” he explains. “Having the clinic
based at the pharmacy is more sustainable than holding it at the
GP practice. It also means I can provide a service on an ad-hoc
basis rather than having defined clinics at the surgery. There
will always
be patients who cannot make appointment times so I will provide
the service whenever I am on duty.” |
And there are
examples of pharmacists prescribing in other areas. At Fisher Pharmacy
in Dunfermline, Anne Eadie and Shona Tarvit started running
a supplementary prescribing clinic for stroke patients last week. Through
the clinic, they will manage patients who currently have uncontrolled
hypertension. “The focus is to monitor blood pressure closely,” explains
Mrs Eadie.
Setting up a stroke clinic in Dunfermline
 At Fisher Pharmacy in Dunfermline, Anne Eadie
(pictured) and Shona Tarvit started providing a new supplementary
prescribing
stroke
clinic last week. Clinics for initial appointments will be held
every other week. “We are aiming to see the first 60 patients
by the end of September. Once we have done the initial reviews
the follow-up appointments will only be for 10 minutes each so
we can be more flexible about fitting them in on other days,” explains
Mrs Eadie. Preparation for the clinic began last month. The surgery
wrote to every patient on its list who had had a stroke or transient
ischaemic attack — a total of 120 patients — to explain
the supplementary prescribing service. Initial consultations take
about half an hour and involve a discussion of the patient’s
condition, any tests needed and preparation of a clinical management
plan. A standard CMP for hypertension is used with adjustments
made where appropriate, eg, for diabetes or reduced renal function.
The patient will be seen at the clinic at intervals determined
by the CMP. “From a patient’s point of view, these
clinics mean better access and closer monitoring. The ultimate
aim is preventing strokes,” says Mrs Eadie. |
In Coatbridge, Lanarkshire, Marie Therese Rogers is working
in the same clinical area but will use supplementary prescribing for
patients with
stable hypertension. She will monitor their blood pressure every three
months in clinics to be held at McNulty Pharmacy. “Three-monthly
blood pressure checks is more often than the GP offers and the pharmacy
is more accessible in terms of its location for most patients,” she
explains.
Addressing hypertension in Coatbridge
 At her pharmacy in Coatbridge, Marie Therese
Rogers (pictured) will be prescribing for patients with stable
hypertension by the
end
of the month. “Nurses and primary care pharmacists already
offer supplementary prescribing in GP practices. We need to offer
something else to be of benefit and that’s why I want to
hold the clinics in the pharmacy,” she explains.
Since refitting her pharmacy to provide consultation space four
months ago, Mrs Rogers has started running a blood pressure monitoring
service.
This has helped her to increase her confidence before she starts
prescribing: like most community pharmacists she is used to talking
to patients every day, but in the shop not in a consultation room.
In the supplementary prescribing clinic, she will monitor patients’ blood
pressure every three months. Patients are currently being identified
from their repeat medication slips. Mrs Rogers will draw up clinical
management plans and agree them with the GP in advance of the clinics. “I
aim to prescribe for a couple of hundred patients. Initially I will
run a half-day clinic each week and then go to a full day as the
patient numbers increase,” she explains. |
Similarly, in Doune, Perthshire, Campbell Shimmins will be prescribing
for patients with coronary heart disease, including patients on complex
regimens involving 10 or more medicines.
Prescribing for patients with cardiovascular
diseases in Doune
 From next month, Campbell Shimmins will be running supplementary
prescribing clinics for patients with coronary heart diseases on
complex medication regimens.
The surgery will refer patients to Mr Shimmins (pictured) and,
to begin with, he plans to see four or five patients per half-day
session.
Referral will be on the basis of a particular care issue so the
clinical management plan will depend largely on this. “I have a number
of template CMPs for specific conditions and drugs. The CMP will
specify how often I see a patient. For example, if a drug is being
added or adjusted, a patient might need to be seen weekly or fortnightly,” he
explains. He will measure blood pressure, recommend any blood tests
needed and adjust medicines as appropriate. “Once the initial
patients reach their therapeutic goals, I will sign them off and
take on new patients,” he says. Initially Mr Shimmins will
run the clinics from the local surgery. “The pharmacy is too
small to have a sit-down consultation room so I will be using a portable
cabin at the surgery which has been installed to allow the practice
nurse, me and other professionals, such as a visiting chiropodist,
to have a consultation room,” he says. But in the longer term,
he plans to extend his pharmacy into part of the shop next door in
order to have the consultation room there. “That way I will
be able to use it on Saturdays so I can see people who work during
the week, and it will fill the gap created by a lack of prescriptions
on Saturdays when the GP surgeries are closed.” |
A striking similarity in three
of the examples mentioned is that all the pharmacists are prescribing
for cardiovascular disease. Mr Scott
is not surprised by this, since cardiovascular disease is a priority
for the Scottish Executive. But he adds that there is a need to extend
the range of areas in which supplementary prescribers are interested. “We
have to work with colleagues in general practice and share out the work.
For example, it might be beneficial for pharmacists to look at patients
who are non-attenders at clinics in general practice but who go to the
pharmacy to collect their medicines,” he comments.
Since the funding was announced, supplementary prescribing in community
pharmacy seems to have a new impetus. Although a prior lack of funding
was not the sole reason that community pharmacists struggled to use supplementary
prescribing, it was certainly a significant factor.
Mrs Eadie explains: “Shona and I qualified as supplementary prescribers
last November. We knew before we started the course that we would use
it to run a stroke clinic but we have been waiting for funding.”
Although Mr Shimmins managed to start prescribing a year and a half ago,
it did not last. He explains: “After an initial flurry of activity
for six months when I optimised medicines for a batch of patients, I
stopped prescribing. Although I have continued to monitor and review
these patients, I no longer prescribe for them and I have not taken on
any new patients.” He says that the lack of funding was challenging: “Having
to make supplementary prescribing work within existing model schemes
money was difficult.”
Perhaps Mr Burton sums it up when he says: “Recognition is the
main thing. The funding shows that the Scottish Executive is willing
to facilitate new ways of working and it means I can move forward without
making a loss.”
However, there is one issue that is still causing some difficulties and
that is access to patients’ medical records. Mr Scott says access
must be agreed at a local level, rather than a broad statement being
made at an Executive level. And this is why a number of different approaches
are being taken.
Mrs Rogers plans to borrow patients’ notes from the surgery on
the morning of the clinic and, after seeing the patient and annotating
the record, return the notes to the surgery in the evening. At Fisher
Pharmacy, the pharmacists visit the surgery to prepare a summary of the
patient’s medical record, which is then used at the clinic. It
includes the patient’s current medication, co-morbidities, drug
allergies, previous antihypertensive treatment, blood test results and
risk factors. In addition, the patient’s notes are flagged at the
surgery so if any subsequent entries are made, the pharmacists will be
alerted. After each clinic, the pharmacist will go to the surgery to
update the patients’ notes.
Mr Burton will be using his own notes system, too — one which mirrors
a system used by asthma nurses so that the notes are in a format that
the doctors are used to seeing. He plans to visit the surgery before
each clinic to check the patients’ medical record for any recent
additions. Future developments
Exactly how supplementary prescribing will be used is still being determined.
Community pharmacists in Scotland are waiting for the detailed negotiations
on their new contract to be completed, and perhaps the outcomes of
these negotiations will partially answer the question. It is expected
that supplementary prescribing will form part of the chronic medication
service, one of the four core services in the new contract. However,
it will be through the experience of the pharmacists running the supplementary
prescribing clinics that the real answers will come: what works, what
does not and where real patient benefit is gained.
Mr Scott’s long-term view is one of expansion beyond prescribing
for a single disease area. “It is early days but clearly pharmacists
have to deal with all medicines in the British National Formulary. So
the strength of pharmacists is that they can look at a patient’s
medicines in total rather than focus on one disease area. Patients rarely
present with just one disease,” he explains. He hopes pharmacists
will use supplementary prescribing in polypharmacy clinics.
Does Mr Scott see supplementary prescribing as a stepping stone to independent
prescribing? “Some pharmacists will never move from that stepping
stone but others will see independent prescribing as the end goal. So,
yes, if those powers are conferred on pharmacists, then I would like
to see them using it. But independent prescribing is about teamwork,
not detachment.”
He explains that the model of independent prescribing he would like to
see is one in which, following diagnosis, a patient’s care is handed
over to a pharmacist who then tailors a medicines regimen to the individual
patient. “If anything, this would involve closer working, since
the GP and pharmacist would have to have complete confidence in each
other.”
The Scottish Executive’s support for supplementary prescribing
continues this autumn when it funds another 180 places for pharmacists
to train as supplementary prescribers. But, in the long term, Mr Scott
wants to see supplementary prescribing become part of the undergraduate
curriculum and he wants all community pharmacists to be supplementary
prescribers. “So the contract will then have to reflect these skills,” he
says. What about those pharmacists who do not want to be prescribers? “Clearly
there will be a transitional phase but, if prescribing is in the undergraduate
course, then it will become as acceptable as dispensing.” And he
is not thinking about a long timescale: just 10 to 15 years “depending
on how pharmacists react to these opportunities”. He concludes: “It
is early days. We have got to explore supplementary prescribing and unleash
its potential. Hopefully this is what we are doing with the new funding
for supplementary prescribing clinics.” |
The
Pharmaceutical Journal