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Paul Saxby
Beth Hird
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Beth Hird, a practice pharmacist who runs an asthma clinic
Beth Hird is the first pharmacist in the UK to qualify
as a pharmacist independent prescriber after completing the practice certificate in
independent prescribing at Keele University (see p37). She also trained
as a supplementary prescriber at Keele and wrote her first prescription
in August 2005.
She currently prescribes for asthma patients in a clinic that she runs
at St George’s Medical Practice in West Bridgford, Nottingham.
The clinic is held once a week and was set up to review and manage patients
with asthma, especially focusing on those with a recent exacerbation,
those ordering a large number of salbutamol inhalers and those that the
GPs believe might be non-compliant. “Patients are generally invited
in to see me, however they may be referred from their GP, or access the
clinic themselves if they have seen me previously,” she explains.
She takes on the management of these patients, through supplementary
prescribing, up to step four of the British Thoracic Society guidelines. “I
generally follow up patients until their asthma is better controlled,
or they fall outside of my area of competence, in which case they are
referred back to their GP,” she says.
Mrs Hird believes that being able to prescribe independently will benefit
patients since they will be able to access her clinics more freely without
the need for her to draw up a clinical management plan. It should also
free more GP time, she says.
Her main anxiety about prescribing independently is that, while she feels
competent to prescribe for patients with asthma, she is concerned that
patients and other health care professionals will expect her to be able
to prescribe for any condition, and therefore outside her area of competence.
However, she has no concerns about being accepted as a prescriber by
patients and other health care professionals. “Over the past 18
months, 99 per cent of my patients have accepted me as a prescriber,
as has the team of health care professionals that I work with,” she
says.
Now that she has qualified, Mrs Hird hopes to prescribe for patients
with acute exacerbations of asthma and to make asthma diagnoses. She
also plans to widen the area within which she is competent to prescribe
to include other chronic diseases, such as hypertension. The GPs are
keen for her to take on statin prescribing within the practice.
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Rachell Hall
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Rachel Hall, a practice pharmacist who manages chronic conditions
“I want to train as an independent prescriber because there are
certain limitations to supplementary prescribing, which can sometimes
act as
a barrier to patient care,” says Rachel Hall, a clinical pharmacist
and supplementary prescriber at The Old School Surgery in Fishponds,
Bristol. “For example, if one of my patients complains of constipation,
which I am competent to treat, legally I cannot prescribe anything
because it is not covered by the clinical management plan. If I were
an independent
prescriber I would be able to treat it straight away.” Currently,
Ms Hall either has to ask the patient’s GP to write a prescription
or recommend an over-the-counter product.
Ms Hall qualified as a supplementary prescriber at the University of
Bath in January 2006. She wrote her first prescription four months
later. She mainly sees patients with chronic diseases, such as hypertension,
type 2 diabetes, chronic renal disease, asthma and chronic obstructive
airways disease as well as some dermatology patients. Patients are
referred
to Ms Hall by GPs or nurses and she reviews their treatment, increases
doses and adds or changes medicines where appropriate using a CMP.
Ms Hall started the independent prescribing conversion course at the
University of Bath in December. Before the course began her expectation
was to learn more diagnostic skills, such as the neurological examination. “But
I am not overly confident I will be able to put this into practice, since
it takes trainee doctors years to master it,” she says. She also
hopes to develop her history taking and physical examination skills,
since these will be essential to forming a diagnosis. She expects the
legal, professional and ethical aspects of independent prescribing
to be covered.
Looking ahead, Ms Hall says that she and her mentor are in the process
of producing protocols to follow for certain acute (as well as chronic)
conditions where, with appropriate training, she will be able to prescribe
independently. She emphasises that the doctors in her practice are
keen to expand her role as much as possible to help with their workload. “I
see independent prescribing as a way of achieving this,” she
says.
“I have no anxieties about becoming an independent prescriber because
I feel that since I qualified I have continued to develop skills and
update my knowledge, which will enable me to do this competently. I
am also willing to take on the extra responsibility of being an independent
prescriber but I will do this in such a way that I reduce risk as much
as possible by following practice protocols, etc. I am very aware of
my limitations,” she says.
Ms Hall will finish the conversion course this month and hopes to qualify
in February. After she qualifies she will continue her role in the
practice, which she expects will expand to include managing acute as
well as chronic
conditions.
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Mahesh Sodha
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Mahesh Sodha, a community pharmacist who runs weekly clinics
Mahesh Sodha works as a community pharmacist in Chelmsford, Essex, and
has been running weekly clinics for diabetes, hypertension and dyslipidaemia
at a two-branch surgery of six GP partners for over two years.
“Because I have a flexible clinical management plan and prescribe independently
in all but name currently, the new training may not change my practice
very much. The main advantage I will have with the new qualification will
be to free me from a clinical management plan that creates a lot of unnecessary
bureaucracy,” he says. He adds that prescribing independently will
also allow him to treat many minor ailments that his patients expect him
to deal with when they consult him for their long-term conditions.
Mr Sodha has treated about 300 patients. However the clinics ended late
last year due to lack of funding. Fortunately, he has been invited to run
a similar clinic at another practice in Chelmsford for the next six months.
“I qualified as a supplementary prescriber from King’s College London
in June 2004 and started running my clinics in September 2004,” he
explains. “The first prescription I wrote was for a diabetes patient — I
initiated metformin and ramipril for him.”
Mr Sodha says that he did not experience any reticence when writing his
first prescription. However in hindsight, he can see that he was cautious
in starting the patient on 1.25mg of ramipril although he had intended
to start him on 2.5mg.
Mr Sodha hopes to start the independent prescribing conversion course at
King’s shortly. He is not expecting that the course will provide
him with clinical examination skills, although he sees these as fundamentally
the weakest area for pharmacists. “I do not believe that a short
course of this nature can do justice to teaching these skills. However,
I hope the course will guide me on how best to obtain and supplement these
skills and ensure that I implement a framework for working within my competency,” he
says. He adds that he has learnt a lot from the GP partners he works with
and believes that this will remain his main source of clinical examination
skills.
“Without sounding over-confident, I am not anxious about becoming an independent
prescriber because I am quite clear about my strengths and weaknesses.
I feel confident about my therapeutics and, while I might dabble in amateurish
examination techniques such as a collapsing pulse test, I always get an
experienced physician to repeat such tests,” says Mr Sodha. He believes
that as long as he only works within his competency and seeks help whenever
he is out of his depth, patients will be safe with him.
After he qualifies Mr Sodha hopes that he can practise as he does now but
without a clinical management plan. He also hopes to expand into new clinical
areas, particularly in minor ailments, international normalised ratio management
and chronic pain management.
“My biggest fear is that there is no clear funding that is ring-fenced
for this work and many pharmacists will end up not using their qualification.
Having [prescribing] as an enhanced service in the new community pharmacy
contract has not been helpful,” he says.
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Nicola Stoner
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Nicola Stoner, a hospital pharmacist who specialises in cancer
Nicola Stoner, lead cancer pharmacist at the Churchill Hospital, Oxford
Radcliffe Hospitals NHS Trust, has not yet written her first prescription
as a supplementary prescriber but is already undertaking the independent
prescribing conversion course at the University of Reading.
Dr Stoner has been working in oncology for over 16 years and completed
a PhD in antiemetics in cancer chemotherapy at the beginning of her career.
After she qualifies as an independent prescriber, she plans to prescribe
antiemetics to prevent chemotherapy-induced nausea and vomiting in a breast
cancer clinic and hopes that she can extend this prescribing to outpatients
visiting the hospital’s day case unit for chemotherapy.
Dr Stoner qualified as a supplementary prescriber from the University of
Reading in July 2006 but, due to staff shortages, has not fully implemented
supplementary prescribing within the hospital. As soon as staff are recruited
she will instigate supplementary prescribing of adjuvant chemotherapy in
the colorectal and breast cancer clinics.
“When I started the supplementary prescribing course I was not thinking
about prescribing chemotherapy. I was thinking more about prescribing supportive
care,” explains Dr Stoner. “However, after doing the course
and talking to colleagues that are prescribing chemotherapy I decided that
this was a better fit with supplementary prescribing,” she says.
With the workload of oncology clinics increasing, and the need to meet
government cancer targets, having pharmacist and nurse prescribers as part
of the team will help to increase the clinics’ capacity.
Dr Stoner believes that being able to prescribe independently will allow
her flexibility and will result in better patient care. “I am often
writing prescriptions for patients and getting them countersigned by a
doctor so, really, it is just making sure that the accountability is correct,” she
explains. She admits that, at the moment, she would not want to prescribe
chemotherapy as an independent prescriber but has not ruled it out in the
long term. “Antiemetics is my area of expertise. I write the policy,
I tell the doctors what to prescribe and it would be so much easier, and
we would be able to provide a better service for patients, if I could prescribe
independently,” she explains.
Dr Stoner believes that, for the area in which she is planning to prescribe
independently, completing the conversion course is simply a matter of dotting
the i’s and crossing the t’s. She explains that she already
has the necessary clinical examination and diagnostic skills, which she
acquired during her supplementary prescribing training through the help
of a dedicated medical tutor. “In practice, the duration of the conversion
course will not allow pharmacists to become experts in clinical examination — doctors
do that for years,” she says.
Dr Stoner has no specific anxieties about becoming an independent prescriber
and says that she is very aware of her responsibilities. |
The
Pharmaceutical Journal