Pharmacist prescribers are becoming less unusual |
Pharmacist prescribing is pushing forward. With 7 per cent of practising
pharmacists in Scotland registered as supplementary prescribers, and
a pharmacist prescribing in 5 per cent of community pharmacies, the agenda
now is about how to make prescribing a mainstream activity.
This is exactly what was discussed at a national pharmacy conference,
held in Stirling on 26 November. “The conference aimed to share
best practice, develop support networks and spread change,” explains
Annamarie McGregor, pharmacist prescribing co-ordinator at NHS National
Services Scotland.
Although being a pharmacist prescriber is becoming less unusual, it is
still hard work and every pharmacist at the conference had to overcome
barriers before starting to prescribe. But Ms McGregor believes pharmacy
in Scotland has reached a tipping point. “With any new service,
once more than 2.5 per cent of people are offering it, you are getting
beyond the threshold where the new practice is restricted to the innovators,” she
explains. Pharmacist prescribing, it seems, is starting to become mainstream.
Bill Scott, chief pharmaceutical officer, Scottish Executive, wants to
see all pharmacists who directly provide patient care become prescribers. “Prescribing
is one of the tools that pharmacists will have to enable and improve
the pharmaceutical care of patients,” he told The Journal. But
he says mass pharmacist prescribing is largely dependent on prescribing
being part of the undergraduate pharmacy degree.
Drawing on experience
Central to prescribing taking off was the Scottish Executive’s
decision to make national funding available for community pharmacists
to run prescribing clinics. “One of the successes of this funding
was its lack of restrictions. It allowed pharmacists to develop their
own clinic, rather than specifying the way in which the money should
be spent,” explains Ms McGregor. “We now have many examples
of how prescribing can be used and, because they have been developed
by the pharmacists who use them, we know these models work in practice.”
Now Ms McGregor is drawing on these examples to create a best practice
guide. The guide will not be restricted to supplementary prescribing.
It will help inform the development of independent prescribing services
too. The guide will provide examples of service protocols and clinical
management plans, and case studies of what individual pharmacists are
doing. Some of the featured pharmacists have told The Journal about their
work (see Panels).
If prescribing is to become mainstream, what needs to happen? First,
pharmacists have to work out how prescribing fits into their everyday
job. As pharmacists develop different roles and areas of expertise, the
profession needs to debate how pharmacists will work together to provide
an optimal pharmacy service.
Many examples exist of community pharmacists who have set up prescribing
clinics, most frequently in hypertension and asthma. It is a fantastic
start, demonstrating that pharmacist prescribing works. But now pharmacy
has to decide how to make best use of prescribing: is it beneficial for
patients to go to one pharmacy for a hypertension clinic then another
for diabetes? Or should community pharmacists be thinking about using
prescribing within a more generalist role, such as making dose adjustments
across a range of therapeutic areas as part of medication review? This
would not prevent them having a specialist clinical area, but perhaps
this needs to form a secondary prescribing service to deal with complex
cases. Such a service could be offered jointly with hospital and primary
care pharmacists, with pharmacists in one locality teaming up to ensure
all clinical areas are covered.
In Glasgow, the case of Alia Gilani (see Panel 2,
p692) demonstrates how the skills of a prescribing pharmacist can complement
those of a
community pharmacist. Without the community pharmacist’s ability
to identify patients — which comes from establishing relationships
with regular patients — the prescribing pharmacist’s role
would be less effective at targeting patients with the greatest need.
“All pharmacists need to work out how our different roles will fit together
and how we support each other, including how we work with our own team,” says
Ms McGregor. This underlines another consideration: how pharmacy staff
fit into prescribing services. Their role as checking technicians — a
way to separate prescribing and dispensing — is frequently mentioned.
But how about more clinical roles, like measuring blood pressure or taking
blood samples? This could help pharmacists to provide a holistic service.
Importantly, pharmacists need to prove that prescribing is a service
that works. David Raeburn, a prescribing pharmacist in Strathpeffer,
says audit is essential. “We need to evaluate what we have achieved
and how patients have benefited. The only way to convince people of our
worth as prescribers is to provide documented evidence,” he explains.
He suggests a national agreement on what to audit is needed — then
all prescribers can produce evidence on the same defined outcomes. Support needed
One of pharmacists’ key demands is a network for prescribers to
swap ideas and practice. Exactly how such a network would be structured
is open for debate: should it be for pharmacist prescribers only or for
all prescribers? Should it be divided into clinical areas? And who should
run it?
Mr Scott thinks this is the sort of role that should fall to the Royal
Pharmaceutical Society. He would like to see cross-professional standards
for prescribing, and is calling on the Society to develop them. “I
would like the Society to raise its game and become the body in Britain
that is coordinating prescribers,” he says. “The Society
should see itself as the body with most interest in medicines and a central
focus for all prescribers. If it will not do this then someone else will.
It is not about creating a set of rules but about developing standards
of good practice, and allowing prescribers to exchange views and support
each other.”
Then there is IT. Pharmacists still have to handwrite prescriptions,
which is time consuming and means that prescriptions are not automatically
added to the patient’s medical record. The other IT issue is the
lack of access to patient’s medical records in community pharmacy:
this, more than any other issue, is preventing prescribing clinics being
shifted from a GP practice into the community
pharmacy.
But there are examples of pharmacists who have found a way around the
problem. Martin Jackson, a community pharmacist and prescriber at Aberdour
Pharmacy in Aberdour, Fife, has access to medical records at his pharmacy. “Initially,
I had access via a laptop. The doctors had a system for out-of-hours
access and we tapped into that,” he explains.
The GP practice with which Mr Jackson works is based elsewhere but uses
premises in Aberdour to run a village surgery. “When these premises
became unsuitable, the practice started to use the large consultation
room in the pharmacy to offer twice weekly surgeries,” says Mr
Jackson. For this to work, the GP computer system had to be available
in the pharmacy. Mr Jackson now makes the most of this access to run
supplementary prescribing clinics for patients with a variety of long-term
conditions including pain, respiratory disease and cardiovascular disease.
Mr Jackson finds it difficult to understand why pharmacy-access to notes
is so unusual. “The technology is available now to allow pharmacies
to dial into surgeries to access notes, or access could be via laptops
or palmtops. There are practical difficulties for pharmacies that deal
with many surgeries but a large number of pharmacies only deal with one
or two surgeries,” he says.
When access to notes is discussed, it is easy to blame the lack of IT.
But the underlying problem is much wider. Doctors are happy for pharmacists
to access records when it is within the walls of the medical practice,
but they are nervous about taking the records out of the practice and
into a pharmacy. Mr Scott admits it is a political minefield. “If
pharmacists, GPs and patients can come up with local agreements like
this then it will demonstrate to politicians that the fears they have
might not be realised,” he says.
Prescribing is certainly on the way to becoming mainstream in Scotland,
but there are still a number of issues that need ironing out and lessons
to be learnt across Britain.
Panel 1: Hospital prescribing in acute situations
How supplementary prescribing can fit into acute situations is
demonstrated by Pamela Mills, principal pharmacist in redesign,
NHS Ayrshire
and Arran. She uses supplementary prescribing in a clinical decisions
unit at Crosshouse Hospital in Kilmarnock. This means she prescribes
in acute, unscheduled care.
The unit aims to make a rapid diagnosis to shorten the length
of a patient’s hospital stay. “The initial problem was how
to adapt the supplementary prescribing model into this acute situation,” says
Ms Mills. The solution was the production of six clinical pathways,
each with standard clinical management plans (CMPs) which are pre-signed
by the clinical director.
The clinical pathways are for non-traumatic chest pain, suspected
pulmonary thromboembolism, deep vein thrombosis, cellulitis, hypoglycaemia
and minor gastrointestinal bleed. Once a diagnosis has been made,
Ms Mills takes over. She follows a standard CMP to start new medicines,
to adjust doses of these medicines according to laboratory results
and to issue discharge medicines. She can also prescribe any of
the patient’s existing medicines.
“Take the chest pain pathway for example. If the patient has an exercise
tolerance test which is positive for an angina diagnosis, I would
then start appropriate medicines — aspirin, statin, glyceryl
trinitrate spray and beta-blockers unless contraindicated. I would
also look at replacing existing medicines that are now contraindicated,
such as non-steroidal anti-inflammatory drugs,” Ms Mills
explains.
Ms Mills is currently the only prescribing pharmacist on the unit
but the pathways are followed by non-pharmacist prescribers when
she is away. This ensures standardisation of care. She advises
pharmacists who are thinking about introducing supplementary prescribing
to produce
similar pathways. “They are useful in making clear exactly
what is going to happen,” she says.
“As more and more pharmacists are becoming prescribers, it enables
us to support each other,” she says. This concept has clearly
worked in Ayrshire where 13 pharmacists in secondary care have
registered as supplementary prescribers and 11 more are in training. |
Panel 2: Three case studies from community pharmacy
and primary care in Scotland
Overcoming GP barriers in community pharmacy
Many GPs are supportive of supplementary prescribing. But what happens
when one GP in a practice is not keen and holds others back from
developing supplementary prescribing? This was the problem faced
by David Raeburn, community pharmacist at The Spa Pharmacy, Strathpeffer.
How did he overcome the barriers? “I did something for the
surgery,” he explains. “They had been asked to review
their elderly patients on NSAIDs to ensure they were all receiving
a proton pump inhibitor. I offered to do the reviews,” he
explains. His input was valued and gave Mr Raeburn the opportunity
to demonstrate his competence. “I was then able to move
on to setting up the pain clinics,” he says.
Mr Raeburn is currently focusing on migraine. The surgery invites
patients receiving migraine treatment to attend a review clinic
run by Mr Raeburn. “In the first appointment, I take a clinical
history and carry out a medication review. I then give the patients
a pain diary. The second appointment is about determining if the
patient is receiving the right treatment,” he explains.
Mr Raeburn has opted to run the clinics in the surgery. He believes
having his presence there is of value to remind the GPs of his role,
and to reinforce to patients the working partnership between the
GP and the pharmacist.
Joint approach to run community pharmacy clinics
If a pharmacist does not want to be a prescriber, or has not yet
undertaken the prescribing training, it should not restrict their
patients’ access to a pharmacist prescriber.
Alia Gilani, pharmacy and prescribing support pharmacist at NHS
Greater Glasgow, has been running prescribing clinics for some time,
focusing on the needs of the South Asian community. A recent development
was setting up prescribing clinics in a community pharmacy where
the pharmacist is not a prescriber. “We were keen to take
the clinics to where people are, so we found a pharmacy in the centre
of the community in Pollokshields,” she explains.
The community pharmacist identifies patients with diabetes or coronary
heart disease, gets patient consent forms signed and then hands
them over to Ms Gilani. She sees the patient at a clinic in the
pharmacy where she conducts a full medication review, issues prescriptions,
carries out investigations and may refer the patient to another
service.
“I have reviewed 81 patients so far and have about 20 on the waiting
list. On average, I see patients for three to nine months,” Ms
Gilani explains. “One of the differences between patients
identified at the pharmacy and those at the surgery is the pharmacy
patients tend to be younger. They want to change their lifestyle
to tackle health issues.”
Practice and community pharmacists team effort
In Dundee, a practice pharmacist and community pharmacist have teamed
up to offer supplementary prescribing clinics. Both can prescribe
and they have contributed different skills to a successful joint
approach.
Jackie Duncan, practice pharmacist at Hawkhill Medical Centre
and Ryehill Medical Centre in Dundee, explains that the starting
point
was building relationships with GPs. “I had been working with
the practices for seven years when I started prescribing so had
built up a relationship,” she says. This made it easier for
community pharmacist Helen Christie of Alliance Pharmacy to start
running hypertension clinics.
“It made sense to start clinics at the surgery so Helen could develop
a relationship with the doctors. If she had started in the pharmacy
then this would not have happened,” Ms Duncan explains. After
a while, they targeted certain patients, including the “do
not attend” group. “This is when we moved some of the
clinics out into the pharmacy because it is positioned near to a
university so catches students who do not attend the surgery. Another
use of pharmacy clinics is on Saturday mornings,” she adds.
What Ms Duncan would like to do next is develop a CMP that covers
all surgeries within the local Community Health Partnership. Dundee
has over 20 medical practices, and a supplementary prescriber currently
needs a standard CMP and prescription pad for each surgery. “We
are now looking at the possibility of getting a CMP that would be
signed by the lead clinical at the CHP. There is a precedent for
this as heart failure nurses in Tayside have a CHP-wide agreement,” she
explains. |
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