The Pharmaceutical Journal
Vol 278 No 7449 p481-482
28 April 2007

This article
Reprint   Photocopy

PDF 60K, Acrobat Reader

Independent prescribers start work

In this second feature in a series that is following four pharmacists as they develop as independent prescribers, Dawn Connelly (on the staff of The Journal) finds out if they have qualified, what they are doing and how they are coping with their new responsibilities

Independent prescribing series

• Beth Hird, a practice pharmacist who runs an asthma clinic

• Mahesh Sodha, a community pharmacist who runs weekly clinics

• Rachel Hall, a practice pharmacist who manages chronic conditions

• Nicola Stoner, a hospital pharmacist who specialises in cancer

Discussion forum

Beth Hird, a primary care trust pharmacist who runs an asthma clinic

Conversion from a supplementary to an independent prescriber has been a simple transition for Beth Hird, a prescribing adviser at Nottinghamshire County Teaching Primary Care Trust. “So far I have ensured that I have continued to see patients for their asthma review, as I did previously using supplementary prescribing. As yet, I have not come across any areas where I have not felt competent,” she explains.

She says that being able to prescribe independently has allowed patients better access to her clinics. “The clinical management plan does not need to be signed by the GP before I see the patient. This means that patients are able to book appointments for the clinic on the day, rather than restricting it to the week before,” she says.

Mrs Hird currently sees about six patients per clinic. “I have made a couple of asthma diagnoses, where the patients were referred to me because the GP thought that they might have asthma,” she explains. She has also referred a patient back to the GP who she considered not to have asthma, based on his peak flow chart.

Asthma reviews can be complex. Mrs Hird recently saw an adult who came in claiming that his asthma was under control. “On further questioning his interpretation of control was only having to use his salbutamol inhaler once or twice a day, as opposed to four or five times daily,” she explains.

The patient was not waking at night with a cough or wheeze, although he did find walking to the shops difficult. He did not have good inhaler technique with a metered-dose inhaler and was using beclometasone 100µg, two puffs twice daily, plus his salbutamol inhaler.

“In my role as independent prescriber, I decided to start a spacer device with the MDI. On review four weeks later, the patient’s inhaler technique was much improved, however his asthma was still not as well controlled as I had hoped. I therefore decided to start a salmeterol inhaler, two puffs twice daily, via the spacer. The patient returned and his asthma had improved with salmeterol but he was still feeling the need to use his salbutamol more than three times a week. I therefore increased his beclometasone to 200µg, two puffs twice daily,” she says. The patient is due to be reviewed again shortly.

Mahesh Sodha, a community pharmacist who runs weekly clinics

Much to his frustration, Mahesh Sodha has yet to qualify as an independent prescriber. However, he has started the conversion course at King’s College London and hopes to qualify in late May or early June. “Sadly, none of us believed that course accreditation would take this long and did not anticipate delays in obtaining qualification,” he says.

In the meantime, Mr Sodha continues to practise as a supplementary prescriber at weekly clinics managing diabetes, hypertension, dyslipidaemia and chronic kidney disease. He runs these clinics at a local GP practice and spends the remainder of the week working as a community pharmacist in Chelmsford, Essex.

“I am about to start four practice sessions with my designated medical practitioner to concentrate on developing plans for longer term continuing professional development based on my areas of weakness,” says Mr Sodha.

He explains that he has made a list of physical examination skills that he intends to pursue over the next six months. “Most of these will be life-long learning commitments, which I will continue well after obtaining the independent prescribing certificate.

“I see this certificate as a beginning to embark on improving and expanding my competencies,” he says. Although Mr Sodha has learnt some physical examination skills on the conversion course, he has identified several additional skills that will be of particular use in the clinics he runs.

“I have realised that interpreting echocardiogram results at an advanced level can be useful in my practice,” he says. “So this whole process for me will be dynamic,” he says.

Mr Sodha believes that he has been completely accepted as an established prescriber by the health care team at the surgery and, more importantly, by patients. “The clinics are always fully booked up to four weeks in advance and patients return for follow-up appointments,” he says.

He is currently funded by the GP practice in which he runs the clinics but is not optimistic that this funding will continue in the future. “The PCT has not committed any funds for pharmacist prescribing and for GPs to pay for this service we have to present a good business case,” he says.

Rachel Hall, a practice pharmacist who manages chronic conditions

Rachel Hall, clinical pharmacist and independent prescriber at The Old School Surgery in Fishponds, Bristol, is adamant that independent prescribing is the future for pharmacy. “I see the future as every doctors’ surgery having a pharmacist prescriber,” she says. “Pharmacists are trained and geared up to do this. This is where pharmacists should have been 10 years ago,” she adds.

Since she qualified as an independent prescriber in February, Ms Hall has continued to manage patients with chronic conditions and sees about 60 patients a week with diabetes, renal disease, hypertension, respiratory disease, dermatological conditions and coronary heart disease. She explains that she now has a much wider role in managing these patients since, unrestrained by clinical management plans, she is able to diagnose and treat minor ailments that she comes across during consultations.

For example, a patient recently had an appointment with Ms Hall for routine management of stage three chronic kidney disease. During the consultation, Ms Hall noticed that the woman was suffering from psoriasis. The patient “did not want to bother anyone” but admitted that the psoriasis was affecting her day-to-day life. Ms Hall is competent in dermatology and was able to diagnose and treat the condition immediately.

“I am pleased that I now have the flexibility to be able to prescribe in different chronic disease areas for the same patient,” she says.

Ms Hall explains that she is feeling more confident in diagnosing conditions as she sees more patients. However, she appreciates that she can always seek advice from the practice GPs if she is uncertain about a diagnosis or feels it is outside her areas of competence. For example, she recently suspected slow atrial fibrillation in a patient that she was seeing for type 2 diabetes. “I had been managing the patient’s diabetes for the past year and was seeing him for a general review. His diabetes was under control but he had high blood pressure. When I was checking his blood pressure I noticed that his pulse was irregular and asked the practice nurse to do an ECG.” The patient’s GP checked the ECG, confirmed the diagnosis and prescribed warfarin.

Ms Hall also sees patients with acute conditions who are referred to her via the practice’s telephone triage system. “If the GPs do not have any slots available for that day, they will refer patients to me,” she says. She has treated patients with rash, conjunctivitis, ear infections and other minor ailments via this system. “Because of the nature of supplementary prescribing, I would not have been able to do that before,” she says. She adds that it has given the GPs some flexibility and taken the pressure off their appointments.

“I always explain to patients that I am a prescribing pharmacist. I think it is really important that they know that,” says Ms Hall. This year, she was included on the surgery’s patient satisfaction survey and received some positive feedback, scoring 81 per cent (GPs scored between 72–83 per cent) on the personal satisfaction rating. The survey covered areas such as whether patients felt reassured, their confidence in the professional’s ability and whether they had the opportunity to express concerns.

Ms Hall has recently started studying a mental health module at the University of Bath and hopes to take on the management of patients who attend the surgery with depression or anxiety.

Nicola Stoner, a hospital pharmacist who specialises in cancer

By introducing a pre-admissions clinic for chemotherapy inpatients, and pharmacist independent prescribing within that clinic, Oxford Radcliffe Hospitals NHS Trust has made more efficient use of its beds. Patients no longer have to wait either to receive treatment or for their discharge prescriptions, says Nicola Stoner, lead cancer pharmacist at the trust’s Churchill Hospital.

Dr Stoner qualified as an independent prescriber in March and immediately started prescribing in the multidisciplinary pre-admissions clinic. Her work in the clinic has made the clinical pharmacy ward service more streamlined. “As part of my prescribing role I am encompassing what I would normally do as a clinical pharmacist, for example, taking a full drug history and checking patients’ own medicines for use on the ward,” she says.

Dr Stoner prescribes supportive therapy (including antiemetics, granulocyte-colony stimulating factor, pain relief, mouth care products and patients’ own drugs) for patients who are due to be admitted for planned chemotherapy. She writes both inpatient charts and discharge prescriptions. “The clinic runs every morning and each patient is given a 30 minute appointment and sees the nurse, staff grade doctor and pharmacist,” she explains.

The first prescription Dr Stoner wrote independently was for antiemetics (ondansetron, dexamethasone and metoclopramide), G-CSF (peg-filgrastim) and paracetamol, lorazepam and levomepromazine, as required.

“This is my area of expertise and I wrote the drug policies. I felt comfortable prescribing because I was confident in my knowledge and am competent in this area,” says Dr Stoner. She believes that her prescription was more comprehensive than that prescribed by the senior house officer at the last cycle, since she ensured that the “as required” drugs were included, something that had been missed in the past.

Dr Stoner would like to prescribe Controlled Drugs in the pre-admissions clinic but is not currently doing so since it would require a clinical management plan to be in place. She hopes that the current consultation on this issue (PJ, 31 March, p355) will have a positive outcome and she will soon be able to start prescribing CDs independently.

One issue that has come to light, says Dr Stoner, is that it is important she remembers which role she is undertaking at any one time. For example, if she is doing a pharmacy clinical ward round she does not prescribe independently. “I would only prescribe as a non-medical prescriber if I knew the medical history of that patient and had taken the time to discuss the prescription with them. When I am providing a clinical pharmacy service to a ward I do not necessarily have the time to spend with that patient in that way,” Dr Stoner explains.

In addition to her work as an independent prescriber, Dr Stoner prescribes adjuvant chemotherapy in a colorectal cancer clinic as a supplementary prescriber.