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Speakers described the benefits and the pitfalls
of pharmacist prescrining in different practice situations. Olivia
Timbs (editor of The Journal) reports
Pharmacist prescribing in practice
Pharmacist prescribing was discussed in all its guises in a session
chaired by Clive Jackson, chief executive of the National Prescribing
Centre,
and Ash Soni, from the National Pharmacy Association.
Mr Soni, himself a supplementary prescriber, launched the session by
putting forward the rationale for independent pharmacy prescribing to
be “full formulary”. In response to the recent Department
of Health consultation on the topic all pharmacy bodies were in agreement
that this was the way forward (although doctors did not want pharmacists
to have access to all drugs).
Mr Soni explained how difficult it would be to put restrictions in place.
Where would the line be drawn, he asked. Restrictions would potentially
disadvantage patients and he cited the example of a pharmacist who could
be treating a patient with diabetes. The pharmacist would be able to
treat the diabetes but if the patient had a cut on the leg that appeared
to be on the point of ulceration, that patient might have to be referred
back to the GP. Pharmacists’ prescribing should be limited only
by any lack of competence in a particular area, Mr Soni argued.
Communication essential
Mr Soni was followed by Nick Barber, of the University of London, who
outlined some of the issues that contribute to good prescribing practice.
He pointed out that there was little literature on the subject but
explained that the fundamental building block of good prescribing was
communication between the patient and the prescriber.
He then described good prescribing visually with a Venn diagram. The
overlap between patients’ wants, the technical properties of a
drug and the general good is what constitutes good prescribing. Although
the technical aspects of a drug are black and white, something that pharmacists
can easily relate to, the other aspects of good prescribing involve making
value judgements, about which pharmacists are less comfortable.
Professor Barber pointed out that pharmacists have to learn that there
are at least two views to a patient, in the way that there are two views
of, say, a mountain. One view is clinical, the other is of the person.
The default position with prescribers usually is that the drug they have
chosen will work and the patient will not suffer any ill effects, although
they have an open invitation to return if they have any problems. However,
Professor Barber argued, the probability of an individual being side
effect-free is impossible to anticipate. In short, he said, patients
need to be treated as people, not as objects. Although it is important
for pharmacists to apply the technical knowledge they have of drugs,
they must be aware that prescribing decisions are made with huge uncertainty
and if the best drug does not suit an individual it should be changed. Voices of experiences
The next two presentations came from pharmacists who have direct experience
as supplementary prescribers: Mahesh Sodha, a community pharmacist
from Chelmsford, Essex, and Helen Williams, who described her experience
in a heart failure clinic at King’s College Hospital, London.
Despite the different environments in which they practise, both speakers
had the same comment to make: they work from generic clinical management
plans that give them the flexibility to adapt to patients’ needs
without continually having to turn to the independent prescriber for
assistance.
Mr Sodha works with a six-partner GP practice and provides care for patients
with type 2 diabetes, hypertension and dyslipidaemia. He highlighted
a number of aspects of his experience as a supplementary prescriber,
including the distribution of a patient satisfaction questionnaire that
revealed that patients are happy with pharmacist prescribers. Mr Sodha
suggested that patients benefit because they are given more time than
they receive with GPs, there is more opportunity to counsel them about
medicine-taking and they can be monitored more closely.
The challenges, on the other hand, were not clinical but administrative.
Selling the value of pharmacist supplementary prescribing to his primary
care trust in order to get money for training and for funding to pay
for sessions had not been straightforward.
Mr Sodha had some ideas of what makes a successful prescriber. It was
important to have a clear focus on how, when and where the prescribing
would take place. Pharmacists had to have good clinical skills already;
they had to have good PCT support and, in their turn, have respect and
support for their independent prescribers.
The importance of good clinical skills was further emphasised by Ms Williams,
who described her experience in a clinic that looks after patients with
heart failure. One of the challenges, she explained, was learning to
do things that are unfamiliar to pharmacists, such as touching patients.
Ms Williams explained that she ran the clinic with a nurse consultant,
who had commented that having pharmacists in the team improved mortality.
Patients are initially diagnosed by a consultant and then their care
is delegated to the clinic. She, too, emphasised the importance of working
within broad clinical management plans when dealing with something like
heart failure because of the necessity to manage
co-morbidities. If the clinical management plan were too restrictive
and a patient then develops gout, for example, the patient would have
to return to the consultant for diagnosis. If the CMP is broad, however,
and the development of gout is recognised to be a possible adverse effect
of heart failure, the patient can be treated in the clinic by either
the nurse or the pharmacist.
Ms Williams also explained that multidisciplinary working leads to better
use of skill mix and leads to consistency in care, the opportunity to
address compliance and greater patient satisfaction, among other matters.
She has also had to learn different skills, particularly in terms of
counselling such as dealing with end-stage heart failure, to talk about
prognosis and palliative care when appropriate and deal with related
issues such as sexual dysfunction. What patients want
Helen Tyrrell: patients want information, access, choice, safety
and effectiveness |
The last presentation came from Helen Tyrrell, of Voluntary Health
Scotland, who looked at the issue from the patient’s perspective in a talk
entitled “What patients want”. The list of what they want
from drugs, according to Ms Tyrrell, includes information, access,
choice, safety and effectiveness.
Many pharmacists might be surprised how little patients understand
what supplementary prescribing means. There is confusion in many people’s
minds between supplementary prescribing and repeat dispensing and emergency
prescribing. And when it comes to treating minor and common ailments,
for example, patients do not have enough information as to why there
are limits on what pharmacists can prescribe for, say, eczema.
Ms Tyrrell recommended that more information is needed on service changes
and definitions, and leaflets could be put in GP surgeries and pharmacies.
She urged the Royal Pharmaceutical Society to ask to put information
on patient group websites. |
The
Pharmaceutical Journal